No, I’m not talking about a need for Facebook for Dogs. I’m talking about the interaction and contact networks that dogs have, which are important for understanding and mitigating infectious disease risks. Let’s use my dogs as an example.

Dog 1: Ozzie

  • PITA (pain in the…) 1 year old Labrador.
  • Healthy, young, low risk for severe respiratory disease.

Dog 2: Merlin

  • 12 year old Labrador with chronic lymphoid leukemia who’s been on chlorambucil and prednisone for close to 2 years.
  • Otherwise healthy (for an old dog with leukemia), but presumably at higher risk for severe disease should he get a respiratory infection.

Ozzie and Merlin’s normal social network:

Their social network is pretty small. It’s predominantly just the two of them. We live in the country and they have very few random encounters with other dogs. They go for walks around our property and sometimes at the local agreement forest, so there’s always some chance for an encounter with another dog, but that’s a rare occurrence (and direct contact with another dog would be rarer still). Every week or so, Heather takes them for a walk with a friend and her dog, who has a similarly cloistered lifestyle.

They have few contacts with other dogs, the limited contact they have outside the household is a known, regular contact that’s low risk. Their risk of exposure to an infectious disease is pretty low (but never zero).

So the cost:benefit calculation is easy for me here. I don’t see a need to or benefit of disrupting their social network based on the current circulation of canine respiratory pathogens. Their network is small, low risk and the contacts are beneficial (for both the dogs and people). If one of the dogs was sick, I have no doubt any visits would be cancelled.

The “holiday effect” on their social network:

Here’s where things get more complicated. When we visit Heather’s family and the whole gang is there, it’s a bit of a gong show. We have Ozzie and Merlin, plus Maggie (adult Golden Retriever), Otis (adult behemoth of a Bernese Mountain dog) and Charlie (adolescent Labrador). That’s actually less than it could be, because Phoebe doesn’t make the trip… probably her own good as a small dog in the otherwise big dog frenzy). Otis and Charlie are from separate households in the same area of the US.

So, we have five dogs from three cities in two countries. They’re all well cared for and none have high risk lifestyles, but Otis and Charlie add a lot of unknown factors to the mix.

Is this a higher risk situation than our normal one? Yes.

Is it particularly high risk?

  • Probably not. It’s short term contact with a known but geographically distinct group of dogs.
  • We know the health status of the dogs and, as far as I know, none of them have any high risk exposures.
  • If there was rampant canine infectious respiratory disease (especially a new pathogen or severe disease) in the area from where any of these dogs came, I might reconsider getting them all together, but that would be case-by-case, since there are important family benefits of getting together (including the dogs).

Last summer’s social network

We rent a cottage for a couple of weeks every year. This year, we realized that “Ozzie + 24 hours at a cottage = not a lot of relaxation.” So, he went to a local day care for part of the day (a tired Ozzie is a much more enjoyable Ozzie). It was a typical day care, with about 20 dogs tearing around a compound. It was great for him, great for us, but absolutely higher risk for spread of respiratory disease, because it involved a lot of dogs that we know nothing about. It was a good day care and they required kennel cough vaccination, which reduces some of the risk, but doesn’t eliminate it.

So, Ozzie got a Bordetella / parainfluenza / adenovirus vaccine, and a lot of potential exposure. Merlin and the rest of us got a break from Ozzie, and we accepted the added degree of risk.

I didn’t give Merlin a kennel cough vaccine, although I considered it. Since he’s higher risk for severe disease, my threshold to get him vaccinated is lower, and it would have been reasonable to do to protect him in case something broke through Ozzie’s vaccine and he brought it home. This summer, if we’re in the same situation, I’d assess Merlin’s health status and the disease status, and decide whether or not to vaccine him too (I’d probably lean toward vaccinating him now).

The cost:benefit calculation was quite different here:

  • We greatly increased our dogs’ social networks and therefore risk of exposure to infectious diseases. However, my risk assessment deemed it worthwhile, for both the dogs and us.
  • If things were going off the rails from a disease standpoint, Ozzie wouldn’t have gone to the day care, dropping our risk back down to baseline.

There’s no standard formula to assess risk and what’s tolerable. We can’t take “x” number of contacts and “y” situations and come up with a magic number. Well, I guess we can, but it’s not going to be useful. However, sketching out a dog’s social network is useful to visualize the risks that are present and to assess each one.

  • Sometimes, you might say “that contact is not really important, it’s high risk and I can change things to avoid it.“
  • Sometimes, you might say, “that’s a risk we have to take.“

If you need to send your dog to day care to go to work, send your dog to day care. Just pay attention to where it is.

If you’re going on vacation, you may need to board your dog. If it’s a high risk dog and a high risk area, you may still have no choice, as a boarding kennel might be the best option. However, you might also be able to find a smaller well-run facility, in-home care or a willing friend to take your dog. There are often other options if you know where to look, and no one-size-fits-all solution.

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There’s still not really a lot to report with the current canine infectious respiratory disease situation in North America, which is probably good news. As ever, we’re largely flying blind because we have no coordinated surveillance for canine infectious respiratory disease, so we’re try to figure out as much as we can through a variety of sources.

Current status:

The hype is dying down. We’re seeing a far fewer reports of disease in dogs, and I’m getting fewer calls from veterinarians. The question is whether that’s because there’s less disease, or because people have gotten bored with reporting or have simply adapted to the current situation. The news cycle is pretty short, as are attention spans, so in the absence of fairly dramatic changes, social media and traditional media usually move on fairly quickly. My somewhat educated guess is that we still have an elevated baseline level of canine infectious respiratory disease complex (CIRDC)(which has been gradually increasing over the last couple of years), and some local outbreaks (as we always have), and decreasing rates of CIRDC in places that reported higher numbers this past fall. Those are all things we expect with the normal waxing and waning of endemic disease.

Where is this disease present?

CIRDC is everywhere, as always.

I get a bit annoyed seeing reports about “the disease” being present or absent in a particular area or those that try to give it a new name like “atypical CIRDC.” Canine infectious respiratory disease has been around as long as dogs have been around. Various respiratory viruses and bacteria are circulating in the dog population all the time, everywhere. When people ask “is it here?!” they’re really referring to an increase in CIRDC (or an increase in awareness of it), not introduction of some specific pathogen. Maps showing where the disease “is” cause confusion, and they’re purely made up.

Increased rates of disease absolutely occur in different areas at different time. When that happens, sometimes it’s missed, sometimes it’s high profile. Almost invariably, rates come down again after a few weeks, as things revert to normal.

Is there a new “mystery virus” causing disease in dogs?

Many good laboratories are doing deep sequencing to look for any new pathogens. The longer we go without anyone reporting something potentially relevant, the less likely it is that something new is involved. It’s possible that (but would be really disappointing if) a laboratory has found something they’re not reporting, but given the number of laboratories that are working on this, if there was a widespread new virus, I’m pretty sure we’d know by now.

My theory is still that the increase in CIRDC is being caused by our regular respiratory pathogens (e.g. canine parainfluenza virus, Bordetella bronchiseptica, canine respiratory coronavirus, canine pneumovirus, Mycoplasma) doing their regular things, just at higher levels in some areas.

What about that weird Mycoplasma-like bug from the laboratory in New Hampshire?

Not much new has been reported on this finding either. It’s good that they’re still working on it, but we’re not hearing similar reports from other laboratories, so it’s probably not a key player. If this bug is a cause of disease in dogs, I’d guess it’s something that’s been a cause of disease all along, but we just didn’t know about it, versus it being a new organism that’s emerged and is spreading in the dog population.

Do our “kennel cough” vaccines still work?

Yes (and no). We have good mucosal (i.e. intranasal, oral) vaccines for some respiratory pathogens in dogs that work quite well. The problem is that they don’t work against all causes of canine infectious respiratory disease. We have vaccines that will cover one or more of Bordetella, canine parainfluenza virus and adenovirus; while they don’t protect against other pathogens, protection against those three is important (especially the first two).

We also have a vaccine against canine H3N2 influenza virus. It’s been in short supply because of production issues over the past couple of years. Canine flu is a sporadic (but locally dramatic) cause of disease in dogs in the US. Like any flu vaccine, the canine flu vaccines are moderately effective and best for prevention of severe disease (versus prevention of infection), and are lower on my priority list for the average dog.

What do we do now?

  • Dog owners should relax. Think about your dog’s exposure risk and susceptibility to severe disease, and make some modifications to their routine if indicated. Talk to your veterinarian about respiratory disease vaccines. And did I mention relax?
  • As for me – Wait. Watch. Continue to collect as much data as we can. Continue to try to walk the fine line between increasing peoples’ awareness of CIRDC and avoiding paranoia/panic.

Why don’t we have a good canine disease surveillance system?

Money, specifically lack thereof. That’s not the whole issue but it’s a lot of it. The broader issues include:

  • Animal disease control and regulation has historically been developed for food animals. Animal health is usually under the purview of agriculture or food safety agencies. So, there is often little or no mandate to cover companion animals, and less expertise. There are often inadequate resources to cover core mandates with livestock species, let alone something peripheral like dogs. It’s not that these groups aren’t interested, it’s mainly that they don’t have the time, staffing or mandate to do much.
  • Limited veterinary infectious disease expertise. The veterinary infectious disease world is pretty small. There aren’t many of us and we have a finite degree of bandwidth.
  • Testing for CIRDC is scattered amongst various private, academic and government laboratories. Those system aren’t currently able to communicate effectively, and there are often various barriers to data sharing.  For effective surveillance, we need a coordinated, real-time system with integration of data across these sources. That’s probably a long way away.
  • There’s very little funding for companion animal infectious diseases, both for surveillance systems and targeted research. I think we get a lot of bang-for-buck with the limited money that flows to the area, but it’s really hard to get any money to investigate things like this. That means we don’t get the data we need and we don’t train more experts in the area.
  • Detailed study of disease situations like this requires collaboration with primary care veterinary clinics. That’s really tough because of the workload that they currently have – they’re swamped. Adding more work (usually unfunded) isn’t something for which most clinics are up, at least on a long-term basis. We can get little targeted studies done with some clinics, but it’s hard to do the broad work that’s needed with financial and IT support to make it viable over time.  

Am I optimistic or pessimistic for where we’ll be with CIRDC heading into 2024?

I’m fairly optimistic. I’ve felt this situation was overblown from the start, with some real disease issues over-amplified by media and social media. I’m not dismissing the real impacts in some areas and on some dogs, but I’ve never been convinced that we have a massive, broad outbreak. There have been real impacts, real concerns, as well as excessive fear, and there’s been a lot of good work done trying to sort this out. Increasing awareness about CIRDC in dogs and disease prevention is always good. As we head into 2024, hopefully we’ll see a continued die-down in reports of (and actual) disease, and improvements in infection prevention.

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The World Organization for Animal Health Health (WOAH, formerly the OIE) has issues a call to countries to live up to their commitments to phase out the use of antimicrobials for growth promotion in animals. This is low-hanging fruit in terms of antimicrobial stewardship that you’d think would have been addressed by now, but is still an issue in some countries (but was phased out in the US in 2017 and in Canada in 2018).

Let’s review some of the language and terminology around how antimicrobials are used:

In animals, antimicrobials can used to treat existing clinical infections (therapy), to prevent infections in high-risk situations (prophylaxis), and to treat animals that are at high risk of already being infected but are not yet sick (metaphylaxis). Those are all considered veterinary uses for antimicrobials, and they’re all justifiable under the right circumstances (though there are still concerns about overuse, particularly with metaphylaxis and prophylaxis).

Unfortunately, antimicrobials are also still used in some places to promote growth of food-producing animals. That kind of use has nothing to do with prevention or treatment of disease. Instead antimicrobials are used in these cases to alter the intestinal microbial populations of the animals, which can result in better growth rates. From a production standpoint, that can be good, but it increases the risk of antimicrobial resistance developing, which can impact animals, humans and the environment.

Another key term is “medically important” antimicrobials, which are those that are the same drug or in the same drug class as antimicrobials used in humans.  If resistance to these drugs develops through their use in animals, that could pose risks to humans. So we definitely do not want medically important antimicrobials used simply for promoting animal growth; they need to be reserved for when they’re really needed (in either animals or people).

The World Health Organization (WHO) categorizes all antimicrobials as either medically important or not medically important, and classifies the medically important antimicrobials into different priority levels (a revision of this classification will be released soon). Pretty much all of the antimicrobials that are used for treatment, prevention or metaphylaxis in animals are medically important, and some of these are also used for growth promotion. There are also various not-medically important drugs that are used for growth promotion. Resistance concerns regarding the use of the latter are low, but not zero, as there’s still potentially an environmental impact (pretty much completely unknown at this point), and we can rarely say there’s absolutely no risk of cross-resistance or co-selection of resistance to an unrelated medically important drug.

In 2016, WOAH member states agreed to stop the use of “highest priority critically important antimicrobials” (HPCIAs) for growth promotion in animals and phase out the use of all antimicrobials for growth promotion “in the absence of a risk analysis.“

What’s happened since then? Not enough:

  • 20% of member countries still report the use of antimicrobials for growth promotion in livestock.
  • It’s estimated that 76% of those countries have not done a risk analysis to try to identify risks and justify their antimicrobial use.
  • At least 50% of these countries have no regulatory framework to regulate use of antimicrobials for growth promotion.
  • In some countries, antimicrobial-containing feeds are not labelled, so farmers and veterinarians may not always know that they are feeding antimicrobials to their livestock (which raises a variety of issues)
  • 11% of member countries reported still using HPCIAs for growth promotion in livestock. This includes the use of colistin, an ol antimicrobial that’s become a drug of last resort for some life-threatening, highly drug-resistant infections in people. That’s a big concern.

Phasing out antimicrobials for growth promotion should be a no-brainer, particularly phasing out such use of medically important antimicrobials. WOAH’s new statement is pretty clear:

“WOAH calls on its Members to restrict the use of antimicrobials solely to veterinary medical use and to actively engage in dialogue with the concerned parties to achieve a total ban on the use of antimicrobials as growth promoters, starting with those that are critically important for human health.”

Is improving animal production important? Yes, particularly in developing countries. Yet, there are better and more sustainable ways to do that than feeding animals antimicrobials for no other reason than improving their growth.

The US Food and Drug Administration (FDA)’s 2022 Summary Report on Antimicrobials Sold or Distributed for Use in Food Producing Animals has been released. It includes some good signs and some bad signs in terms of curbing antimicrobial use (AMU) in the US, but it’s clear we still have a lot of room to improve.

Here are a few highlights from the report (all referring to the US, of course):

  • Antimicrobial use in food animals, based solely on sales and distribution, decreased on a mass (kg) basis by 36% since 2015 (which was the last peak in this measure of AMU).
  • Antimicrobial use increased 4% from 2021-2022.

Comparing to the 2015 historical high and saying “we’re doing a great job” isn’t really a good approach. It’s useful for context, but the year-to-year increase from 2021-2022 is more of a concern, as we really should be aiming for substantial year-to-year decreases in AMU.

For any 2020-2023 data, we always need to ask the question “what was the effect of COVID-19?” We really don’t know in this case, but there could have been impacts on sales and use because of changes in animal management and access to veterinary services. So, I wouldn’t read too much into the 2021 blip; it’s not a great sign, but it’s possibly something we’ll see corrected given some time. We’ll see.

  • The increases antimicrobial sales in 2022 were largely driven by increased sale of tetracyclines, the most common drug class used in livestock, and the one that is probably most ripe for reduction because of its frequent use for prophylaxis.
  • Sales of penicillins decreased by 1%, while sales of aminoglycosides increased by 10%, macrolides increased by 8%, and lincosamides increased by 11% (see figure below).

This raises some concern. From an antimicrobial stewardship standpoint, we’d like to see decreases in sales and use of higher-tier drugs. Here, we’re seeing the opposite: a decrease in sales of lower-tier penicillins with increases in sales of some higher-tier drug classes.

  • The swine industry was the leading consumer, accounting for 43% of total antimicrobial sales for use in animals, closely followed by cattle at 41%.
  • The poultry industry continues to use relatively limited amounts of antimicrobials, with chickens accounting for 2% and turkeys for 12% of sales.

This is unsurprising, and also highlights where we can have the biggest impacts in terms of reducing AMU. It also shows how poultry farmers have lead the way by reducing AMU aggressively and voluntarily.

The graph below shows the different antimicrobial classes used in each species, which is an important consideration. It highlights the dominance of tetracyclines, particularly in swine and cattle. While massive amounts of antimicrobials are used in animals, most of the use is lower-tier drugs like tetracyclines. These drugs are still important in people, but are not as critical as other drug classes as tetracyclines are not typically key treatments for serious disease in humans. The WHO has a prioritization process to categorize different antimicrobial drug classes to help with assessments like this (and an updated version is due to be released imminently).

At the same time, we need to remember that mass isn’t everything, especially when it comes to AMU. In many ways, I’m less concerned about that big fraction of tetracyclines than I am the small fractions of cephalosporins and fluoroquinolones. The latter are important drug classes in humans, and we know that use in animals can contribute to antimicrobial resistance (AMR) in human pathogens. So that small degree of use in animals might have a disproportionate impact on AMR overall. It’s one of the reasons that crude mass-based metrics like this aren’t good a good way to set targets for AMU, but they get used because they’re the easiest to measure.

  • All medically important antimicrobial were used for “therapeutic indications,” as a result of the ban of use of antimicrobials for growth promotion in 2017 (see figure below).

That’s good. Non-veterinary/non-therapeutic use of medically important antimicrobials isn’t needed, so it’s low hanging fruit when it comes to reducing AMU. However, we have to acknowledge that “therapeutic use” is a designation, not necessarily what was actually done, as there’s still massive overuse of antimicrobials in animals in situations where there’s no evidence that there would be a therapeutic effect (including prophylaxis).

Ultimately the FDA report provides some mixed signals overall. We’ll need to see how things develop over the next few years to determine if there was a COVID-19 effect on these data. Regardless, it’s abundantly clear that we still have a lot of room to improve, and we need to act now.

Zero antimicrobial use in animals isn’t a realistic goal. We need to use antimicrobials for animal health and welfare purposes, but we need to use them better.

I’d guess that a substantial amount of antimicrobials that are purchased for use in animals are actually used to “treat” people: they make the user feel better for doing something, while doing little or nothing to actually make the animal feel better in many cases. We have lots of situations where antimicrobials are needed in animals, but we still have massive overuse that needs to be eliminated.

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In case anyone would like a break from all the canine infectious respiratory disease (CIRDC) posts, take a moment to gawk in disbelief (as I did initially) at this human-created debacle:

Skunk purchased from Michigan breeder tests positive for rabies.

How many things are wrong with this, just based on the headline? Ugh.

For the record, breeding and sale of skunks as pets is legal in at least some parts of the US, but it is NOT legal in Ontario. In order to have a captive skunk in Ontario you need to be an authorized wildlife custodian. Animal species native to Ontario cannot be kept as pets. That is especially important when it comes to rabies reservoir species like skunks and raccoons, for reasons aptly demonstrated by this situation.

They don’t know how or when the skunk in question got infected with rabies – a very common refrain. Unfortunately even a lot of dog and cat owners don’t realize the potential for their pets to be exposed to rabies through contact with wildlife, especially bats. Bat bites can be almost impossible to find on a furry pet (sometimes they’re even hard to find on people), so if you don’t see the bat you might not realize there was an exposure. Your pet doesn’t even need to go outside to encounter a bat, because bats regularly get into houses (one way or another!). Keeping your pets vaccinated against rabies is the best way to provide protection against these potentially unseen exposures (and in Ontario, rabies vaccination is legally required for all dogs, cats and ferrets over 3 months of age – that’s 3 months, not 4 months!).

It can take months for signs of rabies to show in an animal after its been infected. Even if the animal looks perfectly healthy, it can still be incubating the virus. (The animal doesn’t become infectious to others until after the virus reaches the brain, but it may still appear normal for some time after this, before it starts to get sick). This is also part of the reason imported dogs from rabies endemic countries remain a risk for at least 6 months after their exposure risk becomes controlled (which is usually when they’re imported). There’s a great little whiteboard video from the Ontario Animal Health Network that explains more about rabies risks in imported dogs (and why just vaccinating them for rabies prior to import doesn’t solve the problem).

While efforts to control an outbreak of raccoon-variant rabies in Ontario since 2015 have pushed case numbers down to just 6 cases in skunks in 2023 (shout out to the Ministry of Natural Resources and Forestry!), they’ve had 17 rabies cases in skunks in Michigan this year, which is a good reminder for anyone who travels (especially with their pet) that the rabies risk can vary considerably by region, even within the US and Canada, and especially internationally in countries where canine-variant rabies circulates.

Also remember that even though there have only been 6 cases of raccoon-variant rabies in Ontario in 2023, we’ve identified 49 cases in bats right across the province, so keep those pets vaccinated, please!

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Spoiler alert: there’s not a lot new to say about the ongoing situation with canine infectious respiratory disease in North America. Most of this I’ve said before. Talk seems to be dying down in a lot of areas, but whether that’s because there are fewer cases or people are just getting bored of talking about it is unclear. It’s probably a combination of both. Based on some data I posted last week and talking to people on the ground in different regions, it seems like most areas that have had a (real or perceived) increase in canine infectious respiratory disease complex (CIRDC) cases are returning back to baseline. Presumably, there are some other areas where disease is ramping up, as usual. However, there are still a few questions worth bearing in mind at this stage:

Is this really an outbreak?

I’d say it’s not so much an “outbreak” as a gradual increase in the incidence of CIRDC over the past couple of years, with typical periodic spikes of disease superimposed over top of it. We have fairly clear evidence of more cases in some areas, usually following the typical outbreak pattern where cases go up, then return back to baseline levels. We also have areas where there’s really nothing too different happening.

Is there a “mystery virus” causing the increase in cases?
This is commonly reported in news headlines, but there’s no evidence of that. There’s a lot of viromics work underway, where they sequence any and all viral bits present in a sample to look for anything new. Since nothing has been found (or at least reported) thus far, it’s becoming less and less likely that there’s a new virus causing any substantial number of cases. I’d also expect a bit of a different disease pattern with a new, highly transmissible virus. More time and more testing will provide more details but at this point, I don’t think we have a reasonable suspicion of a new pathogen.

What about that strange little bacterium reported by the lab in New Hampshire?

This bug needs to be investigated more, but it’s not looking like a leading candidate at this point. It hasn’t been found to be a potential important cause of respiratory disease elsewhere (although I’ve only heard of one place that’s said they’ve looked and failed to find it). We need to learn more about this bacterium, but I’d guess that it’s either just part of the normal bacterial microbiota in dogs or it’s a potential cause of disease that’s been around for a long time, we just didn’t know (and therefore didn’t test for it). I doubt it’s a new bug that’s just recently emerged and spread in dogs in North America.

Are the reported cases of CIRCD more severe?

I don’t think so. Concerns about severe disease in dogs are probably more of a media effect. With typical CIRDC, we expect a small percentage of dogs to get pneumonia, and an even smaller percentage to have serious disease and die. That’s always been the case. When the number of dogs with CIRDC goes up, the number of dogs with severe disease will go up proportionately. So, we’d expect to see more cases of severe disease when we have an more cases during outbreaks, not because the disease itself is more severe, but simply because there’s more overall illness. If we have 100 dogs with CIRDC, we’d expect maybe 1-2 severe cases. If we have 1000 dogs with CIRDC, our severe case numbers jump to 10-20, even if the disease itself is no different.

What about treating dogs with CIRDC with Paxlovid?

Ugh. Horrible headline writing has driven requests to use this drug in dogs with CIRDC.

Please don’t.

We have inadequate dosing data and little understanding of safety for Paxlovid in dogs, and no evidence that its use is necessary (or effective) in any of these cases

What about treating dogs with CIRDC with chloramphenicol?

UGH X2. Chloramphenicol is an antibiotic. It’s a great drug, but (as for all antimicrobials) should only be used when it’s really needed. This drug has fairly important animal and human health risks (even just handling the drug), so we should not be using it routinely; however, if I have a multidrug-resistant bacterial infection in an animal, and chloramphenicol appears to be the best option to treat it, I’ll use it. Standard treatments still apply for routine cases of CIRDC. If we start using Paxlovid and chloramphenicol routinely (be it out of fear, panic or just the desire to do “something”), I have little doubt that we’ll harm more dogs than we’ll help.

Is “kennel cough” vaccination in dogs worthwhile?

Yes. We have good vaccines against canine parainfluenza virus and Bordetella bronchiseptica, two important causes of respiratory disease in dogs. Protection is much better with “mucosal” vaccines that are given directly into the nose or mouth, so that’s the kind we want to use routinely for these pathogens. The vaccines won’t protect against all types of infectious respiratory disease, but reducing the risk of some major ones is still very helpful. Intranasal and oral vaccines are given once, then re-dosed annually. There’s currently nothing indicating we should re-vaccinate dogs more frequently than this.

Are some dogs at increased risk of infection with respiratory pathogens?

Risk of infection depends heavily on risk of (and amount of) exposure. Dogs that encounter a lot of other dogs, especially transient groups of dogs of unknown health status, are at increased risk of pathogen exposure. The more dogs encountered, the closer and more prolonged the contact, and the less certain the health status of the dogs involved, the greater the risk.

Reducing the overall number of dog contacts, particularly contacts with groups of dogs of unknown health status (e.g. random groups of dogs at an off-leash park, versus a small consistent group of known dogs at a day care or play group) is an important control measure.

Are some dogs at increased risk of severe respiratory disease?

Generally yes. We know there are some dogs that have a greater risk of severe respiratory disease or death if they get infected, so we want to be extra cautious with them, including avoiding exposure, vaccination and getting them to a veterinarian sooner if the dog gets sick. High-risk dogs include older dogs, very young puppies, dogs with pre-existing heart or lung disease, dogs with compromised immune systems, and brachycephalic breeds (i.e. flat-faced breeds like bulldogs).

Why might CIRDC rates be increasing?

It’s just a guess, but we could have a pandemic-associated confluence of factors that have led to more dogs with greater susceptibility to respiratory infection.

Changes in how we have interacted over the past few years, and how often dogs go to kennels or daycare (which is often the trigger for getting a kennel cough vaccine) could plausibly have reduced overall vaccination coverage in the dog population. Also, if fewer dogs were exposed to respiratory viruses over the past few years, there may be more dogs that are susceptible to them now. I try to stay away from the “immunity debt” discussion, since that’s more political than scientific, and it’s triggering for some people (my inbox is a testament to that). Nonetheless it’s quite logical that less immune protection from less vaccination and less infection over the past couple years could mean more susceptible dogs. It’s not “debt,” it’s just deferred exposure.

From a severe disease standpoint, changes in the popularity of different dog types could be playing a role too. The French bulldog, a higher risk breed, is now the most popular dog in the US. That’s plausibly going to increase the number of cases of severe disease just based on numbers.

What should the average dog owner do?

  • Breathe. This is not a doggie plague sweeping across the nation.
  • Consider your dog’s risk of exposure and whether you can do things to reduce it, while not being unnecessarily disruptive to life in general (e.g. if your dog needs to go to day care for you to work, send your dog to day care).
  • Consider your dog’s risk of severe disease when deciding whether to change your behaviours and how much to change.
  • Talk to your veterinarian about respiratory disease vaccines.
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This wasn’t on my bingo card for 2023, but it looks like I need to comment on the use of Paxlovid in dogs with respiratory disease. I guess I shouldn’t be surprised, but there’s been a lot of buzz about a single report of a veterinarian using Paxlovid to treat one dog with respiratory disease – in the absence of any definitive diagnosis as to what was making the dog sick.

Some media reports are claiming Paxlovid cured the dog. Did it?

Probably not. I suspect the dog got better on its own despite Paxlovid (not because of it), but can’t say for sure. However, I can say that I don’t see any evidence that we should be using this drug in dogs, and I have a variety of concerns about its use in this manner.

Concerns about Paxlovid use in dogs (quick version)

Paxlovid is an antiviral that we know basically nothing about in dogs. We don’t have dosing or safety info in dogs, and we don’t have evidence that the respiratory disease we’re currently seeing in dogs in North America is caused by a virus that’s susceptible to Paxlovid. So, I don’t think its use is appropriate in such cases, and I suspect widespread use of Paxlovid in dogs would result in harming more dogs than it would help.

Concerns about Paxlovid use in dogs (longer version)

Using a human drug in a pet isn’t rare in veterinary medicine, and often it can be appropriate. Veterinarians often need to use drugs in an extra-label manner, since many important drugs are not licensed for use in animals. When we know how to use the drug, its safety and that it’s likely to work in an animal, this kind of extra-label use can be appropriate.

  • The less we know about things like dosing and safety in animals (which can be very different across species), the greater the risk.
  • The less we know about efficacy, the lower the value.

Treatment is typically a cost-benefit decision, based on assessing potential risks, potential unknowns and potential beneficial effects.

Paxlovid is a combination of two antiviral drugs, nirmatrelvir and ritonavir, which are both protease inhibitors, neither of which are used in dogs. The combination has been shown to be beneficial for treating COVID-19 in some types of people, in some circumstances, with the right timing. That’s based mainly on study of Paxlovid use in unvaccinated people. In Canada, it’s licensed for use in people with mild to moderate COVID-19 who are at increased risk of severe disease. It’s not meant for everyone, and it’s meant for early treatment. There are different opinions about whether it’s really of much use at this point in the pandemic, but I won’t get into that.

What do we know about Paxlovid in dogs?

Pretty much nothing. I’m not aware of any dosing or safety information.  The only thing I can find is a study that looked at Paxlovid in serum of different animal species, including dogs (i.e. they added the drug to serum in a tube, but they did not give the drug to the live animals) and did a pharmacokinetic study on just two healthy research dogs (Greenfield et al 2023). That’s a start, but the small number of dogs (2) means it still doesn’t tell us too much. The researchers reported some pretty major differences between species, including between dogs and people. They concluded that “Some species (rabbit,dog) demonstrated high plasma protein binding (PPB) that was concentration-dependent, whereas others (human, monkey, rat) did not. This can have a major impact on understanding concentration-effect relationships for both efficacy and safety endpoints. As such, it is important to consider PPB when selecting animal species for studies aimed towards understanding efficacy and safety in humans.”

My take home message from that study is it can’t tell us anything about how/if we can and should use Paxlovid in dogs, and we can’t assume safety and efficacy data in people apply to dogs.

Sometimes we use the same doses in people and dogs for a specific drug, but sometimes, the doses are quite different.

Some drugs that are useful in people also work in dogs, but some drugs do not.

Some drugs that are relatively safe in humans are relatively safe in dogs, but some human drugs are highly toxic to dogs.

If we don’t know dosing and safety in a particular species, it’s really hard to consider use of a particular drug if there isn’t a huge potential upside, e.g. because we need to treat a severe disease and we have no other options, and where the drug has a strong chance of working. That’s not the case here with canine respiratory disease and Paxlovid.

Could Paxlovid work in dogs?

Paxlovid could have an impact on some viral causes of canine infectious respiratory disease complex (CIRDC), such as canine respiratory coronavirus (which is a completely different virus than SARS-CoV-2, despite the similarity in name). However, even IF Paxlovid has effects on canine respiratory coronavirus, or other relevant viruses, that may not really mean a lot clinically. It might shorten disease and/or might reduce the risk that secondary complications developing, but that would probably still be dependent on very early treatment, something that is not likely to happen in a lot of dogs when illness is still mild, particularly given the cost of Paxlovid.

Could use of Paxlovid in dogs hurt?

Absolutely. We have no idea if the drug is safe in dogs. There are various known side effects in people, and the drug interacts with a lot of other medications. If we’re going to apply a cliché, it should be “above all, do not harm” vs “it can’t hurt.” The latter is not likely true.

What about developing resistance to Paxlovid?

There’s probably very little risk of viral resistance to Paxlovid increasing due to use in dogs. The concern would mainly be about development of resistance in viruses that can affect people, since that’s where the drug is most often used and where resistance is most likely to have a significant impact. Dogs can be infected with SARS-CoV-2, but for resistance to be a risk, a dog would have to be infected with SARS-CoV-2 at the time it had respiratory disease (likely unrelated, since SARS-CoV-2 is unlikely to cause clinical respiratory disease in dogs based on what we know) AND resistance would have to develop while the dog was infected AND that resistant virus would have to be transmitted back to a person. Dogs seem to pose very limited risk for transmission of SARS-CoV-2 to humans, so it’s fair to assume that the health risks posed to humans from use of Paxlovid in dogs are very low to negligible.

However, we understand little about antivirals and antiviral resistance in animals, and the precautionary principle would have us remain pretty conservative with their use, and to only do so after a thorough risk assessment.

At this point, my assumption is that widespread use of Paxlovid in dogs would harm more dogs that it would help.

In contrast, there’s a different story about another COVID-19 drug in cats. We have some good data about the antiviral drug Remdesivir in terms of dosing, safety and efficacy for feline infectious peritonitis, which is otherwise a pretty much invariably fatal disease. This is a drug we should be using in cats, but we still can’t get (legal) access to it in North America. We’re working on that, so it will probably be the topic of a post in the near future. Good or bad news? I don’t know yet.

In situations like the ongoing concern with canine infectious respiratory disease complex (CIRDC) in the US, where we don’t have any semblance of a surveillance program, we can sometimes try to piece together the picture using different data sets and observations; insurance claims can be a valuable part of this. At our webinar on canine respiratory illness earlier this week, we were able to present some preliminary data based on pet insurance claims through Trupanion. The data are biased, since insured dogs are only a small subset of the whole dog population, but they can still be informative (especially when we don’t have much else on which to go).

The full video of the webinar, along with some other resources, is available on the Trupanion website, but I’ll give a snapshot of the of the data we presented. We’re working on more and hopefully will be able to piece together a more complete story with more data over time.

Here are few interesting slides from the webinar:

This graph shows respiratory disease claims from January 2021 to October 2023:

  • We’ve had a gradual but pretty impressive increase in respiratory disease claims over the past 2 years. Note that these data are adjusted for changes in insurance patterns, such as increasing numbers of dogs with insurance policies. This fits with my general observation from this time period that we’ve been seeing more disease, but not a sudden dramatic boom.
  • We see general ups and downs.
  • We’re at a high point now, consistent with recent concerns.

The map below is important. It shows states and provinces where there’s been an increase in respiratory disease claims year-over-year from August to October in 2022 vs 2023:

  • High rates of claims were/are present in some areas where there’s been a lot of buzz.
  • Some impressive increases have been seen in areas where we’ve had less buzz. I always get questions from Ontario veterinarians asking if we’re seeing more CIRDC cases, but I’d say it’s not much more lately than anytime over the past few years. Most often, I get asked “is that thing that’s going on in the US going to hit us here?” I think this map shows that we can’t just focus on media/social media reports to tell us what’s happening, because they can over-amplify issues and at the same time, some things might fly under the media radar.
  • Claim rates haven’t changed in most areas, though. We’re not seeing something sweeping North America, we’re seeing patchy disease. That fits with my current guess as to what’s really going on (see details below).

Oregon’s an interesting state to look at as an example. This graph shows canine respiratory-related claims in Oregon from 2021-2023, which demonstrates a typical epidemic curve with a nice increase followed by a corresponding decrease in 2023:

  • There was clearly something going on earlier this year. It didn’t seem to get much attention until it was already on the downswing, though. Talking to a few different people in Oregon, the perception seems to be that things have died down over the past month or two, and that’s consistent with the data from this graph.

This graph compares canine respiratory disease claims in California and Oregon for the last few years:

  • California has had an increase in respiratory disease claim rates too, but the pattern looks different. While Oregon had a big peak and then a return to the increasing baseline, California has had a gradual but sustained (and impressive) increase over time, eventually reaching about the same rate as Oregon overall.
  • Does California have more of a well-distributed higher rate of disease? Or, since California is a big state, have we had rotating outbreaks in different areas that end up looking like a steady increase? We’ll need to do a deeper dive on the data to figure that out. The graph shows that something’s going on in California too, but maybe in a different manner than in Oregon.

Let’s jump to some Canadian content. Here’s the graph of canine respiratory disease claims in Quebec from 2021-2023:

  • This one surprised me. I’ve been getting questions about CIRDC cases in Quebec but nothing that stood out as unusual. (Maybe there’s more in the French-language media than I’ve been seeing.)
  • The total number of claims is still relatively small, so we have to be careful not to overreact, but that’s a pretty big percentage increase.
  • The time frame is also different from the Oregon peak. There’s always a bit of a lag with insurance report data, so we can’t say whether this has hit its peak in Quebec yet, or if it’s still increasing or if it’s already on its way down.
  • Regardless, the pattern fits with something that’s been going on recently and is possibly ongoing. We’ll have to see how the numbers trend over the next few weeks.

When it comes to other factors that might increase insurance claims, we have to consider the influence of recent media attention. If a dog had mild respiratory disease (e.g. cough, runny eyes but eating well and otherwise pretty healthy), it might not normally be taken to a veterinarian. However, if the owner is freaked out because of all the news coverage about CIRDC, they’re more likely to take that dog to a veterinarian now versus in previous years. Those cases then end up in an insurance dataset like this (or in a testing dataset from a laboratory) because of owner factors, not dog or disease factors. One way to help tease this out is to look atmore expensive claims, or claims that involve things that would only be done on sicker dogs (eg. oxygen therapy). Our preliminary look at those data showed similar but more blunted trends in terms of increases in some areas, gradual increases over time overall, and no change in most regions. So, the increases we’re seeing in overall claims are probably pretty reflective of true changes, though likely with some fear-driven (vs disease-driven) increases.

Other things we need to consider are what types of dogs seem to be over-represented, beyond regional effects. Preliminarily, claims involving brachycephalics (squish-nosed breeds) seem to be significantly more common, which isn’t overly surprising as these dogs may have less tolerance of any form of respiratory disease. More to come on that.

What’s driving severe disease is also really important. Mild respiratory disease isn’t ideal, but we’re more worried about pneumonia and severe illness that can make dogs really sick, result in high veterinary bills, and kill a small percentage of dogs. Brachycephalics, senior dogs and dogs with pre-existing heart or lung disease are probably at higher risk for severe disease, but we need to look at the data more to confirm that.

Where does this take us?

As we get more data, look at disease patterns over time and locations, and talk to more people about what they are seeing, I’m increasingly convinced that this is a situation of the usual suspects (our normal CIRDC pathogens) doing their usual thing (mild disease in most dogs with a small subset that get pneumonia and a small subset that get really sick), but at a higher rate. I think the rate has been increasing for a while, which makes the normal ups that we see with waxing and waning disease more obvious. I think it’s clear that we’ve had true increases in disease in some areas, but not all, and that clusters are following the typical course of “what goes up, comes down.” Media attention is amplifying the concern, so that we’re hearing more about a lot of things we wouldn’t normally, but there’s a true disease underpinning to those reports.

Why? What is driving the increase in disease rates?

The “why” is unclear, since we still don’t really know the “what” well. When I think about what drives increased disease, I focus on dog factors and bug factors. We have various logical reasons why this increase could be driven largely by dog factors. For example, in the past few years, we’ve seen:

  • More dogs
  • Disrupted veterinary care (less vaccination)
  • Changes in human activities (e.g. more remote work, maybe leading to fewer dogs at day care and therefore less kennel cough vaccination)
  • Other changes in human activities that alter how dogs interact
  • Changes in the types of canine respiratory disease vaccines we use
  • Earlier pandemic restrictions reducing the normal level of exposure to kennel cough pathogens and vaccination

The net result would be an increase in dogs with less immunity from vaccination or previous infection.

For bug factors, I think about the possibility of:

  • A new pathogen
  • An existing pathogen that’s changed

We don’t currently have any clear evidence of either of these bug factors. The story about a previously unknown small bacterium that has been found by the New Hampshire veterinary diagnostic laboratory is still worth investigating, but at this point it’s not clear that it’s driving anything. If this bug turns out to be a pathogen in dogs, most likely it will be a “new to us pathogen” versus a “new pathogen” scenario. By that, I mean that it’s more likely that it’s a longstanding cause of disease that we’ve never diagnosed before, versus a new bug that’s recently emerged and is starting to spread. The current disease patterns don’t really fit with emergence of a new highly transmissible pathogen.

I’m open to new evidence and other opinions, but at this point, if I had to make a somewhat informed guess, I’d go with the assumption that we have patchy but significant increases in disease in some areas across parts of North America, but driven by our normal bacterial and viral causes.

We also have to avoid over-interpreting the insurance claim data, since it’s just one piece of the puzzle, albeit a potentially important one. Everyone always wants definitive answers “now,” but that’s not how outbreaks or outbreak investigations go (especially outbreaks in dogs where we have almost no funding for formal surveillance or analysis of any kind).

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There’s a lot of concern about respiratory disease in dogs at the moment, so it’s a opportunity time to revisit some routine preventive measures that we really should be using all the time (but unfortunately sometimes fall by the wayside). This post focuses on precautions for dog groomers, but really it applies to a broad range of places where dogs go.

Infection control is typically pretty straightforward and boring (which is why it often gets neglected). There’s nothing really fancy and it’s mostly pretty low tech – mainly a matter of using some good general practices and a solid dose of common sense.

With canine infectious respiratory disease complex (CIRDC), the main transmission concerns are from direct contact between dogs, contact with oral/nasal secretions (e.g. shared bowls, licking the same spot soon after another dog) and respiratory aerosols (from coughing, sneezing, heavy panting etc.). There is always a risk of disease transmission at dog grooming facilities, regardless of whether there’s an outbreak going on in the area or not. Various diseases are always circulating in the dog population, and sometimes we can’t tell when an animal is infectious to others, so we apply routine infection control practices in all situations, and increase those when we identify increased risk.

Some routine, every day infection control practices include:

  • Communication so owners know not to bring sick dogs to the groomer. If clients are being called or emailed with appointment reminders, add a statement about cancelling if the dog is sick. (Sound familiar? Lots of what we did for people during the pandemic can also be applied for control of disease transmission in dogs).
  • Business practices that don’t encourage owners to bring sick dogs (e.g. no charge if someone cancels at the last minute because their dog is sick. Yes, a policy like that can be abused, but we don’t want incentives for people to bring in a sick dog).
  • A housing setup that keeps dogs separated. At a minimum, we want no (or very limited) direct contact between dogs.
  • Good ventilation, such as having an in-room HEPA filter or two, especially in dog housing areas.
  • Routine use of personal protective equipment. Ideally, groomers should wear something over their street clothes that’s easy to change if it gets contaminated. If street clothing or scrubs are the only layer they’re wearing, it’s important to have a change of clothes handy. However, it’s easier and better to immediately take off a lab coat, smock or gown than it is to go go somewhere to change clothes completely.
  • Hand hygiene, such as washing hands or using a hand sanitizer between animals.
  • Cleaning and disinfection of areas and shared equipment between animals. Any routine disinfectant should work against typical canine respiratory pathogens, but I always like to use as good a disinfectant as possible. If you can get it, I’d use an accelerated hydrogen peroxide (AHP) product.

Routine stuff is, well, routine. It’s not rocket science (and pretty boring in the end) but it’s the core of good infection control. However, we also need to have a plan for higher risk situations. Ideally, this plan is written out and communicated to everyone in the facility before a situation happens, so it can be implemented by everyone without delay or confusion. Human factors are usually the biggest problem when we see infection control breakdowns.

How to respond to a dog with respiratory disease at a grooming facility

Even with good use of routine practices, it’s possible for a sick dog to get in once in a while. Sometimes people don’t realize or don’t care that their dog may be infectious, and it’s not always obvious as they walk in the door. There are generally two main scenarios:

1. Sick dog is identified as it arrives

 This one’s easy. Ask the owner to take the dog home right away. If there’s a need to discuss anything, ideally the dog should be removed from the facility and the discussion is done by phone. Otherwise, the discussion could take place outside, or inside after the owner puts the dog in a vehicle (if it’s safe to do so). While this is happening, attention should be paid to any other dogs in the vicinity, to keep them away from the sick dog.

There’s not a lot to do with the airspace by the time this happens. Aerosol transmission is the main concern here, and that’s only for a short period of time and over short distances. The risk of something wafting around the building in the air for a long time is low. The pandemic taught us the importance of good ventilation and air filtering, so it would be ideal if there was already a well-ventilated space and a HEPA filter running to further reduce the risk.

Any personnel that had direct contact with the dog before it was removed should change their outerwear and wash their hands.

The general environment is probably fairly low risk but it’s not zero, especially surfaces the dog may have licked, nosed or coughed/sneezed on. Disinfecting those surfaces ASAP would be wise. Having a spray bottle with disinfectant handy is good for many things, and would help speed up the process here too.

If the owner wants to reschedule, we don’t have a good handle on how long to wait, since we won’t likely have a diagnosis for the dog. Waiting a month would be ideal. It’s not a guarantee that the dog won’t still be shedding something, but we’re trying to balance protection and practicality. At a minimum, I’d want to wait two weeks before the dog comes back.

2. Sick dog is identified after being dropped off and the owner leaves

This creates challenges since “get the dog out ASAP” may not be an option. Owners should be contacted to pick up the dog as soon as possible. While waiting, the dog should be kept in an area away from other dogs. Ideally, every facility should have an area to isolate high risk dogs. It doesn’t need to be an isolation unit like in a veterinary clinic, but there needs to be a plan for housing dogs with respiratory disease, diarrhea or other things that get flagged as a concern after drop off. This could be a separate room, or even a well-ventilated storage room or closet, that can hold a crate. The idea is to get as much physical separation between the sick dog and other dogs as possible.

When we can’t physically isolate the dog, we try to contain it as much as possible and use procedures to reduce cross-contamination risks:

  • Keep the dog as far away from others as possible.
  • Position the dog such that there’s limited airflow toward other dogs (e.g. if there’s a window or fan blowing, make sure the high risk dog isn’t upwind).
  • If there are banks of cages, keep the sick dog on the bottom.
  • Put a blanket or something similar over the cage front to reduce aerosol spread.
  • Avoid handling the dog as much as possible. If you have to handle it, either put on single use (disposable or direct to laundry) outerwear like a gown and use gloves. Wash your hands after removing gloves when you’re done.
  • When the dog leaves, disinfect any items in the cage (e.g. bowls), launder any blankets/towels and disinfect the cage.

It’s all pretty basic, but basic is effective if done right.

I’ll write more about where we stand with the ongoing CIRDC situation, but it is a good reminder that we should be upping our routine infection control game.

Dr. Mike Lappin and I are teaming up with Dr. Carrie Jurney (President of Not One More Vet) and Dr. Steve Weinrauch (Chief Veterinary/Product Officer of Trupanion, founder of MightyVet) for a webinar about canine infectious respiratory disease complex (CIRDC) issues in the US (plus some Canadian content). There may be a lot of “we don’t know yet” comments, but we’ll have some insights, some reasonable guesses and, yes, a bit of new data about the situation.

Disclaimer: This webinar is coordinated by Trupanion, a pet insurance company, but it’s a non-commercial talk, and we’re not being paid to do it. We’re just hoping to get some good information out to a broader audience by making use of Trupanion’s interest and reach.

Here are the details about the webinar and how to join:

Trupanion is inviting pet parents and veterinary professionals to join a free, live webinar – “Separating Fact, Fiction, and Uncertainty: Canine Respiratory Illness Q&A” to be held Thursday, November 30, 2023, at 4:30 PM PT / 7:30 PM ET.

This timely event will include: 

  • REAL-TIME UPDATES: Stay informed with the latest updates on canine respiratory illness, leveraging Trupanion’s database of over 3 million Trupanion-protected pets.
  • PREVENTION STRATEGIES:  Learn effective strategies and practical measures you can take to safeguard your pup’s health.
  • SIGNS TO WATCH FOR: Learn how to recognize early signs, empowering you to take proactive steps to address potential concerns.
  • LIVE ANSWERS TO PARTICIPANT QUESTIONS: Participants can engage directly with the panel of experts to ask questions about canine respiratory health.

EVENT DETAILS:

FEATURED SPEAKERS:

  • Panelist | Dr. Scott Weese: Dr. Scott Weese is a veterinary internist, a Diplomate of the American College of Veterinary Internal Medicine, and a Fellow of the Canadian Academy of Health Sciences. He is a Professor at the Ontario Veterinary College, University of Guelph, Director of the University of Guelph Centre for Public Health and Zoonoses, Chief of Infection Control at the Ontario Veterinary College Health Sciences Centre, and is a member of numerous national and international committees dealing with infectious diseases and antimicrobial resistance, including the Quadripartite (WHO, WOAH, FAO, UNEP) Global Leaders Group on AMR. 
  • Panelist | Dr. Michael Lappin: Dr. Michael Lappin is a veterinary internist, a Diplomate of the American College of Veterinary Internal Medicine, holds a PhD in Parasitology, is Director of the Center for Companion Animal Studies at Colorado State University School of Veterinary Medicine and Chair of the World Small Animal Veterinary Association One Health Committee. He is also currently a Professor at the College of Veterinary Medicine and Biomedical Sciences at Colorado State University. 
  • Special Guest | Dr. Carrie Jurney: Dr. Carrie Jurney is a veterinary neurologist and practice owner at Remedy Veterinary Specialists in San Francisco. She is a passionate advocate for mental health and wellbeing, and serves as the president of Not One More Vet 501(c)(3), the world’s largest wellness-focused charity for veterinary professionals. 
  • Host | Dr. Steve Weinrauch: Dr. Steve Weinrauch, BVMS, MRCVS is the Chief Veterinary/Product Officer of Trupanion and founder of MightyVet 501(c)(3). Before joining Trupanion, Steve built and ran three veterinary practices in the Seattle area. He has published his research in numerous peer reviewed journals, and he is licensed to practice in both the U.S.A. and the European Union.

Please note: the webinar recording will be available for on-demand viewing at https://k9illness.trupanion.com/