Tan puppyThere’s no answer to how Asian H3N2 canine flu arrived in North America, but importation of infected dogs seems likely. There seems to be quite a bit of dog movement from Korea to the US, as highlighted in a couple of articles below. There’s no way to know for sure, but well meaning yet unregulated dog “rescues” are probably a leading candidate for how the virus got here in the first place. January 2015: Twenty-three dogs rescued by Humane Society International from a dog meat farm in Seoul arrived in Washington, DC… As for the rescued dogs, after some quarantine time and health checks, and some additional socialization, they will begin the final leg of their journey: finding homes. Some dogs will stay at the Animal Welfare League of Alexandria, which coordinated the shelter placement of the dogs here in the United States. Snowball and several other dogs will go to the Fairfax County Animal Shelter, and still more dogs will head to the Animal Welfare League of Arlington, the City of Manassas Animal Control and Adoption Shelter, Loudoun County Animal Services and the Washington Animal Rescue League. HSI, the international affiliate of The Humane Society of the United States, is working to reduce the dog meat trade in Asia, including South Korea, where dogs are farmed for the industry. HSI hopes to work with more South Korean dog meat farmers to help them transition out of this cruel business. March 2015:  Fifty-seven dogs and puppies have been rescued from a dog meat farm by Humane Society International and Change for Animals Foundation in South Korea. The dogs are now on their way to new lives in Northern California. HSI flew the dogs to San Francisco to be evaluated and treated for medical issues at the San Francisco SPCA. Some of the dogs will be transferred to additional HSI Emergency Placement Partners, including—East Bay SPCA, Marin Humane Society and the Sacramento SPCA. After a brief quarantine, they will be evaluated, spayed and neutered, treated for any medical issues, and made available for adoption. It will be at least two weeks before adoptions are possible. These are probably just the tip of the iceberg when it comes to importation of dogs from Asia.

Dog on blanket(1)Infection control in veterinary clinics has come a long way in the past few years. However, there are still many challenges, and new situations like the large H3N2 canine flu outbreak in the US Midwest raise more issues. Just like human hospitals, vet clinics need to be proactive to reduce the risk of flu virus transmission between visiting patients. There’s always some inherent risk because sick animals go to vet clinics, and because healthy animals can also shed flu virus; however, there are ways to reduce the risk. One of the most important and easiest things to do is to query each dog’s health status and potential for influenza virus exposure at the time the appointment is booked, if the dog will be coming in in the next few days.

  • If the dog has signs that could be consistent with influenza, or if the dog may have been exposed, it can be handled differently at admission (see below).

Have vigilant front office staff looking for sick dogs.

  • If a dog enters the clinic and looks sick (and there isn’t a known non-infectious cause for it), it should be flagged as a flu suspect.

Put a sign up on the door asking people to not bring dogs into the clinic that have a cough or that have potentially been exposed to canine influenza virus.

  • Instead, have them call ahead (even if it’s from the car) or come into the clinic without the dog first.

Have a plan for handling suspected cases that make it to the clinic.

  • The goal is to make sure sick dogs stay away from other dogs, and that personnel handle them with appropriate protective gear (to prevent personnel from passing it on to other dogs via their clothing).
  • Once you have a plan, write it down so that all the staff are clear on the details and can refer back to it as needed.
  • Have the owner call upon arrival or come into the clinic without their dog to check in.
  • Admit the dog directly to isolation through a side or back door, if possible. Otherwise, take it directly to isolation or an examination room, avoiding contact with other dogs.  Do not let the dog wait in the waiting room.
  • Handle the dog from the start using enhanced protective clothing (e.g. disposable gloves, designated gown or lab coat) that will not be used on other patients.
  • Use good general infection control practices. Wash hands after removing gloves. Change protective gear properly so that underlying clothing is not contaminated. Clean and disinfect the environment and common contact items (routine disinfectants, if used properly, will easily kill influenza virus).
  • If a suspect must be hospitalized, keep it in isolation and use proper isolation protocols.

It’s not rocket science, nor is it expensive or time consuming. Like most good infection control practices, it just takes some common sense and attention to detail.  

Dog nose(1)Cornell University, the Wisconsin Veterinary Diagnostic Laboratory and the National Veterinary Services Laboratory has indicated that the large, ongoing canine flu outbreak in the midwest US is being caused by an H3N2 influenza strain, not the expected H3N8 canine flu strain. Molecularly, the strain is closely related to H3N2 strains that are circulating in dogs in China and South Korea. H3N2 canine flu emerged in that region in the mid 2000s and is widely circulating in some areas. This raises a few questions: 1) How did it get here? The importation issue comes up again, but potential sources need to be investigated. 2) Will the canine H3N8 vaccine provide any protection? I suspect no. 3) Does this change the response? Not really. Identifying potentially infected dogs and keeping them away from other dogs is still a key control measure. Vaccination is unlikely to be effective but still isn’t a bad idea, in case it provides some limited protection and/or if there is also H3N8 circulating in the region. 4) Does this explain why the outbreak is so big and seems to be expanding? Maybe. I’ve been a bit surprised at the scope of this outbreak given what we know about H3N8 canine flu. This strain might be more transmissible, shed for longer periods of time or have other differences that make it spread more easily in the dog population. The Asian H3N2 strain has been shown to be highly transmissible and able to cause severe disease (Kang et al Vet Res 2013). 5) Who else can get infected? Asian H3N2 has been shown to be able to infect cats (Song et al, J Gen Virol 2011). There is currently no evidence of human risk, as far as I know, but this needs to be investigated since flu viruses are unpredictable. Given the large number of infected dogs, it should be possible to determine whether there are some associated human cases. The risk is pretty low but it’s wise to look.

A GoFundMe campaign is underway to pay the vet bills for a sick dog that was imported from Ecuador. The whole story can be found on the site but the quick version is as follows:

Someone from the Ottawa area was in Quito and saw a street puppy she liked. On her last day in Ecuador, she noticed he was looking sick. She took him to a local vet but he got worse overnight to the point that he was ‘barely able to hold himself up.’ So, she brought him home to Canada with her. I wonder about the ethics of subjecting a critically ill puppy to a couple flights and a long trip, but he survived the flight and was successfully treated for parvoviral enteritis in an Ottawa veterinary hospital. The outcome’s obviously great for the dog and I can completely see how someone would do this.

However, the bigger issues need to be considered.

  •  Why is a dog adopted on the day or travel, with no vaccination or other medical history, allowed into the country?
  •  Why is a sick dog allowed into the country?
  •  Why is a sick dog that has not been vaccinated against rabies and which can barely hold itself up (and therefore showing signs that could be consistent with rabies) allowed into the country?

It’s not the owner’s fault. She’s not expected to know anything about rabies or any other infectious disease risks that this dog could pose (although subjecting a sick puppy to this type of journey without necessarily being able to afford the required medical care is another story).

The bigger issue is why Canada has pretty much the most lax importation requirements of anywhere on the planet. We’re importing disease because of this (and we have enough of our own to worry about).

There was a good outcome to this story, but if the puppy was rabid (certainly not an uncommon situation in street dogs in many countries) or had some other important infectious disease, the situation could have been much worse.

Dr. Stephen Page, regular supplier of good material, sent me a couple papers from the Quarterly Journal of Medicine the other day. One’s an interesting report of ‘Staphylococcus intermedius’ infection in a person, in a case report entitled ‘A canine bug in a human heart’ (Koci et al, Q J Med 2015;108:337-338).

It’s almost guaranteed that this wasn’t S. intermedius but rather S. pseudintermedius (some medical microbiology labs are apparently still a couple decades behind in identifying this bug). Regardless, it’s an interesting case of a 58-yr-old man with a pacemaker that developed fever, chills and a headache. He reported that a neighbour’s dog had licked his hand a few weeks earlier. The pacemaker incision site was unremarkable but ‘Staphylococcus intermedius’ was isolated from two different blood samples. That’s a concern because of the potential for infection of the heart valves and/or the pacemaker leads. Infections like that can be serious and hard to eliminate (especially since we know that S. pseudintermedius tends to produce biofilm, which helps it hang around sites like pacemaker leads and avoid antibiotics. Fortunately, after a couple rounds of antibiotics and removal of the pacemaker system, he recovered uneventfully

It’s interesting (and encouraging) that the dog exposure was reported. Whether he offered the info or they asked isn’t clear, but this is the type of information that’s often missed.

Putting this report into perspective is important. This, and various other reports of S. pseudintermedius infections, show that this dog-associated bacterium can cause disease in people.

Yet…

  •  Single cases continue to appear in the medical literature. That means it’s really rare (since a single occurrence is enough to prompt a publication).
  • The relative risk from exposure is limited. Most dogs carry this bacterium and huge numbers of people are exposed every day. So, the incidence of disease with respect to exposure is incredibly low

While ‘low’ is good, it’s not much consolation if you’re the one with the rare but life-threatening infection. So, some basic (common sense) practices are indicated. Avoiding contact of dog saliva with open wounds would be one. Good general hygiene practices (especially handwashing), avoiding contact with feces and similar basic measures are probably the key….along with making sure physicians know about animal contact and think about potential zoonotic infections. That’s particularly true for people that are at increased risk of disease.

 

 

The White House has released a "National Action Plan for Combating Antibiotic Resistant Bacteria". This follows on the heels of "Executive Order 13676: Combating Antibiotic-Resistant Bacteria" which was issued by President Barack Obama on September 18, 2014, along with the "National Strategy for Combating Antibiotic-Resistant Bacteria" presented by the President’s Council of Advisors on Science and Technology (PCAST).

The 63-page document addresses several key areas, including preventing spread of resistant infections, improving surveillance of resistant bacteria in both animals and people, development of better and more rapid tests to diagnose resistant infections sooner, development of new therapeutic options and vaccines to treat and prevent infections, and improving international collaboration on all these fronts. With the US being Canada’s biggest and closest trading partner, hopefully there will be a ripple effect that will result in some action on the Canadian side of the border as well.  It will be interesting to see how much actual "action" comes from it in any case, but it’s great to see the subject getting addressed at such a high level.

Pet treats are widely used, and for good reason. Treats can be useful training tools, and pets typically like treats (and owners like to make their pets happy). But even something as simple as feeding pets treats carries some risks (and not just to the pet).  Balancing the risks and benefits is the key. For example:

Pathogens

  • I have to start with this one, since Worms & Germs are what we deal with here. Pet treats have been implicated in a few different outbreaks in people. Salmonella-contaminated pig ear treats are historically the main offender, but any animal-based treat that is not processed to kill pathogens (e.g. cooking, pasteurization, irradiation) is a concern.
  • While pig ears used to be the primary culprit when it comes to contaminated treats, now, you can go into some pet stores and get dehydrated "insert almost any body part here" – lung, trachea, liver, ear, etc. Presumably these items carry a similar degree of risk for Salmonella if they are otherwise unprocessed.

Toxins

  • The main concern here is chicken, duck and sweet potato jerky treats from China, which have been implicated in a large number of pet illnesses and deaths, including at least 1000 dead dogs. No reason for the Fanconi-like syndrome associated with these treats has been identified, and therefore there’s no way to test the products to ensure the same problem won’t happen again.

Injuries

  • Hard treats can result in tooth damage or fractures, which can be both painful and expensive to address.
  • Treats with sharp edges (e.g. bone fragments) can cause damage to the intestinal tract as well.

Obstructions

  • Dogs eat stuff they’re not supposed to all the time (at least mine does). Most often, it’s not a problem, but sometimes it is. If a pet swallows a large piece of a poorly digestible treat it can cause an intestinal blockage. Realistically, this is of limited concern for most edible treats, but is a bigger issue with toys and things like rawhides.

Obesity

  • Weight gain and obesity aren’t usually considered when thinking about problems with treats, but a lot of treats are high in calories, and obesity isn’t just a problem with pet owners. As with human snacking, moderation is the key. Also remember that sometimes size does matter, as  demonstrated in a recent study of bully sticks (dried bull penis) in which is was determined that these treats contained 9-22 calories per inch (Freeman et al., Can Vet J 2013).

Before giving it to your pet, think about the treat, how to use it and what problems might occur. Most treats, particularly those that are not raw animal product based (e.g. pig ears), not prone to fragmenting (e.g. bones, especially cooked bones) and not excessively hard (e.g. bones) are okay in moderation.

One question that’s come up recently is whether pig hair in or on treats can be a problem…

For some, pig hair on their dog’s treats has a bit of an "ick" factor (although it’s a little odd to see people freak out about some hair and then feed their dog a chunk of bull penis or the ear of a pig), but is there really a risk?

  • I can’t see there being any realistic concerns.
  • A dog would have to eat a massive amount of hair-laden treats to have any potential concerns about obstruction (and even then the risk would be remote at best).
  • Hair could be contaminated with various bacteria, like other raw animal parts, but if the treat is cooked (or otherwise treated to kill bacteria) that becomes irrelevant. Certainly, it’s fair to ask whether hair is supposed to be there but I wouldn’t get worked up about it. I’d be more concerned about whether the treat is processed to kill pathogens and fed in moderation (to reduce caloric intake more than hair intake).

A recent rat bite fever death in a six-month-old Pennsylvania baby raises several issues that parents need to consider.

The child died of meningitis and myocarditis (inflammation of the heart) caused by the bacterium Streptobacillus moniliformis. This bacterium is present in the mouths of virtually all rats, and is the cause of rat bite fever. Human infections are uncommon but they can be severe, especially in young children, individuals with compromised immune systems and/or when infection is not diagnosed promptly. Rat bite fever is (not surprisingly, given the name) mainly associated with rat bites, but can also occur if there is other contact of rat (or other rodent) saliva with a person’s mucous membranes (e.g. mouth, nose) or broken skin.

In this case, the baby was bitten by a rat that was to be fed to the family’s snakes.  A few days later, a fever and rash were noted (classical rat bite fever signs) and the child was taken to an Emergency Room, but discharged with "medication" (probably just something to lower the fever). Two days later, the baby was returned to hospital with fever and lethargy, and died later that day.

Besides the tragedy of the situation, there are several things about this case worth pointing out:

  • Babies should not have any contact with rats. Infants are at increased risk of infection from a lot of things, and they get little benefit from touching a rat.  The risks outweigh any benefits.
  • If an infant is bitten by any animal, antibiotics are often indicated to prevent infection. Good bite first aid and knowing when to get medical care should be an integral part of pet ownership
  • Pet owners need to know about infectious disease risks associated with their animals (and any animals they may feed to their animals, as in this case), especially when there are high risk indiviualds in the household.
  • Physicians need to know about bites and other animal exposures. It’s not reported whether the physicians asked, and given the fact that rat bite + fever + rash absolutely screams "RAT BITE FEVER," they must not have. 
  • Patients/parents need to volunteer information about pet ownership and high risk incidents like bites. If the physician had asked about animal contact, or the parents had mentioned the bite, odds are good that the baby would have been treated for rat bite fever the first time the family went to the hospital, and then likely would have survived. 
  • Snakes (or any other reptile) should not be kept in households with babies. The risk of Salmonella exposure is too high.
  • Live rodents should not be fed to reptiles. There are humane issues for both the rodent and the snake, as snakes can be seriously injured by prey.

People talk about "one medicine" and "one health" all the time, but application of the concept is poor. There needs to be better communication about zoonotic diseases and animal exposure, especially in situations like this.

More information about rat bite fever is available on the Worms & Germs Resources – Pets page.

Every year, the American College of Veterinary Internal Medicine (ACVIM) commissions "consensus statements" on specific topics. They’re developed by an expert panel, put up for review by ACVIM members (board certified veterinary internal medicine specialists), and published in the Journal of Veterinary Internal Medicine.

Hot off the (electronic) press is the 2015 ACVIM Consensus Statement on Therapeutic Antimicrobial Use in Animals and Antimicrobial Resistance. Assembled by an international group of experts in infectious diseases, microbiology, internal medicine and pharmacology, it’s an expansion on the highly regarded 2006 equivalent.

To download the consensus statement, click here.

 

If you’re a regular reader, you’ll note the recurring theme of "every animal (and person) is carrying multiple microbes that can harm you, given the right circumstances. Fortunately, the right circumstances don’t usually occur."

There are situations in which those risks increase, and understanding cost-benefit is a key aspect of disease prevention. Sometimes pet factors increase the risk, such as being of a certain species (e.g. most reptiles), young in age, or having an illness (e.g. diarrhea). Sometimes it’s human factors that increase the risk, such as immune status, poor animal handling practices, behavioural issues, or the impacts of diseases or medical treatments.

An example of the last one was published in a recent edition of the Canadian Journal of Infectious Diseases and Medical Microbiology (Poliquin et al 2015). It’s a review of peritoneal dialysis-associated infections caused by Pasteurella, a bacterium commonly associated with pets (especially cats). It doesn’t really tell us anything new, but it’s a reminder of the risks that are present in certain situations.

Peritoneal dialysis is a procedure used in some people with kidney failure. It involves placing a catheter into the abdomen through the body wall. Fluid is then put into the abdominal cavity through the catheter, and removed a short time later, taking with it various substances that would normally be removed by working kidneys. As opposed to hemodialysis, which removes these same substances directly from the blood, peritoneal dialysis can be done at home; however, the catheter has to be left in place and managed properly to prevent infection. Here’s where the pet risk comes in.

The Poliquin paper reviewed records of Pasteurella isolates from peritoneal fluid from patients in the the Manitoba (Canada) Renal Program from 1997-2013. They also looked at published reports of Pasteurella peritoneal dialysis-associated infections.

In total, they identified 37 cases: 33 caused by Pasteurella multocida and four caused by other Pasteurella species.

  • Affected patients had varying degrees of illness, with abdominal pain, nausea and vomiting being most common.
  • Two individuals also had bloodstream infections with P. multocida. One was very sick with a "shock-like syndrome."
  • Contact with a cat was implicated in 83% of cases.
  • Direct contact between a cat and peritoneal dialysis equipment was reported in 25 cases. Ten of these involved the cat puncturing (teeth or claws, presumably) the line or fluid bags.
  • Infections linked to a known bite or puncture of the tubing had a much quicker onset (15 hours vs 44 hours following other contacts).
  • Two people required an ICU stay.
  • The peritoneal catheter had to be removed in 11% of patients.
  • No one died.

As I said, nothing too surprising but more data to support some basic concepts:

  • There are lots of people on peritoneal dialysis living at home with cats. The incidence of this problem seems to be low. However, low incidence doesn’t help much if you’re the one with the infection. So, preventive measures are still worthwhile.
  • Pasteurella can be found in the mouth, nose and feces of most (or all) cats, so testing cats for the bacterium makes no sense. Trying to eliminate Pasteurella from its natural host would also be futile, so instead focus on keeping it out of the person’s abdomen.
  • Since direct contact was documented in most cases (and probably occurred in at least some of the other cases), keeping cats away from peritoneal dialysis catheters and all associated items is important. That should be easy to do, and is probably a key control measure.
  • Since Pasteurella is present in most or all cats, patients should practice good hygiene around their pets, especially hand hygiene. That’s particularly true before handling the peritoneal catheter site or any equipment.
  • Punctures of the tubing or other equipment should be considered a high-risk situation. Part one is keeping the cat away. Part 2 is getting medical advice when a puncture does happen, since prophylactic antibiotics might be indicated.

Image from www.mayoclinic.org (click for source)