Slàinte & steps towards veterinary spectrum of care

Christmas lights.jpg

The holidays can be a whirlwind of lights, colour, joy and in my house kids (& dogs) amped up on Santa-induced excitement and treats. There is no other time of year quite like it. However, there is a dark side to the holidays, and as every vet clinic staff member knows (especially those on emergency duty like I just was)…the season can be cold, bleak, and/or simply sad for many- whether 4 footed or two. For some, the diminished dazzle of the season can be related to economic and/or emotional concerns (i.e. sadness, depression, anxiety, or compassion fatigue), and this can be true for animal owners as well as vet teams

In the veterinary profession we are taking baby steps towards recognizing the challenges related to rising economic concerns (i.e. increasing veterinary costs), and the snowball effect that lack of coin has (especially at this time of year) on reducing pet visits to veterinary clinics. This down-sizing (and decrease in dollars available to spend by animal owners) has considerable impact on animal welfare. The most extreme example of which being an increase in decisions to end a dog, horse, or kitty’s life on the basis of financial factors.

Moving forward into 2019 and onward, there is a strong need for veterinarians who are prepared to assess, communicate, and deliver approaches to animal owners which include healthcare options along the spectrum of care, i.e. a range from lower cost to those regarded as ‘gold standard’ (+/- more expensive). Whether options that vary in cost also vary in effectiveness may be an open, yet undetermined (and potentially controversial) question…In other words does the ‘gold standard’ treatment really have a better outcome for the patient and owner? …And although it pains my clinician brain to think it, that is exactly the type of question that ties into a rising need for (and application of) evidence based-medicine and the day-to-day use of this in clinical practice, i.e. a vet clinic near you (and me). Other question examples could include, ‘What is the evidence for promoting one diagnostic test or treatment over another?’ and do we (i.e. you, me, ‘the experts’…whomever those people are) consider that evidence ‘good?’.

A recent publication sought to raise awareness of this need for veterinary spectrum of care. Additionally, the commentary didn’t just ‘chit chat’ about need….but proposed action initiatives to try to improve access to care for animal owners and also overcome barriers that prevent veterinary interventions to these across a wide spectrum of health care needs.

Unsurprisingly (at least to me), the bulk of these ideas centred on:

1) Awareness,

2) Education,

3) Research, and

4) Communication.

Because it’s the holidays, (aka my noggin’ is full of egg vs. brainpower), I’ll take a 24 h break (and another thoughtful read of the article) before making an attempt at summarizing a few of this fresh new group’s target areas for veterinarians & the profession.

B’Lyme-y, should I vaccinate the dog or not?

(Or…all I want for Christmas is for somebody to tell me if I should advise vaccination for K9 Lyme disease)

Lyme disease in Canada.jpg

On the fairly long list of things the average veterinarian might request from the rosy cheeked & jolly one this holiday season, (after world peace and mandatory pet insurance plans), might be a wish for clear consensus on all things related to Canine Lyme disease.

Failing that, a definitive stance on one aspect, Lyme vaccination, would be kind’ve nice.

Well, Santa (or a team from the University of Guelph) and a sackful of PRISMA prepped systematic review, may have come a bit early this year. Since, seriously, nothin’ says Christmas like meta-analysis, eh? However, bear with me when I translate (likely poorly) that these types of terms reflect a solid attempt by this group of researchers to try and deliver to practicing veterinary clinicians (and pet-owners) a much-needed evidence-based assessment on a topic that doesn’t require a cup of cocoa or a simmering fire to get folks heated. 

Using defined inclusion and exclusion criteria, or a ‘what’s out and what’s in’ list to tackle assessment of studies that reported the use of Borrelia burgdorferi (the agent of Lyme disease) vaccines in dogs, the researchers started with 1570 studies. That seems like a lot…. but using their standardized criteria, they ended up with 3 observational (the most current dated 2005) and 13 challenge studies (with only 5 of the 13 (38%) done in the past 10 years, and all done in dogs < 18 m of age).  

little drummer boy.jpg

Don’t worry, I am getting to the holiday miracle (or epiphany) portion of this, i.e. should we (or should we not) consider Lyme vaccination effective? [Cue the little drummer boy] The summary of evidence completed by the researchers suggests that vaccination lowers the risk of clinical sign (lameness, anorexia, fever) development in vaccinated dogs vs. unvaccinated dogs.

grinch.jpg

However, it is worthwhile (IMHO) to keep reading. [Cue the Grinch, get ready to have your heart shrink 2 sizes too small] As the article goes on to raise a number of concerns regarding study aspects frequently assumed when chatting about Lyme research, such as, were ticks infected with B. burgdorferi (i.e. did anyone check?), were dogs classified as negative before the study began (i.e. did anyone screen for B. burgdorferi status?), and ‘Are these articles relevant for the current vaccines (i.e. have vaccines changed over the years? And if so in what direction?’). Okay- I admit that last concern was mine.

Similarly, there was only one observational study that looked at clinical signs, and as the researchers quite rightly point out, clinical signs of Lyme disease are not all created equal…and this lack of information on clinical signs (individually or clumped together), their duration or severity is fairly critical (essential) for those of us attempting to make recommendations based on risks of clinical disease and with respect to prioritization of canine quality of life.

It is tough to weigh the pros and cons of a vaccine decision without having the questions the researchers outlined answered. However, I think this research team has earned a wassail (or at the very least a latke) for raising further awareness regarding the lack (and limitations) of studies on Lyme disease. Particularly the need for clinically focused studies (i.e. those performed in the field), as unfortunately, a disease model (along with a gold standard test) for B. burgdorferi and Lyme disease in dogs continues to remain on future ‘letters to Santa’ wish lists. 

Engorged tick.jpg

It’s going to require some serious sugarplums (or a nutcracker) to entice veterinarians to initiate and participate in broader based studies reflecting what occurs in general veterinary practise for many (most) K9 diseases and prevention strategies. And until this style of research occurs, I’ll assume that Santa is going to leave me (and my still unanswered question regarding Lyme vaccination) on his ‘naughty’ vs. ‘nice’ list.

 

Rat-a-tat-tat (or Rin-Tin-Tin-Tin) …K9 Sentinels marching in

Rin Tin Tin.jpg

There are certain words that guarantee my interest, and a short list of these (in no particular order) would include: Dogs, Canada, Infectious, Food, and the names of my two human children (probably accessing the internet right now). As such, I was thrilled to see a review article featuring the first three, Dogs as sentinels for Human Infectious Disease and Application to Canadian Populations: https://www.mdpi.com/2306-7381/5/4/83

The publication takes on the valiant task of summarizing research utilizing man’s (or in my case, woman’s) best friend, Canis familiaris (aka the dog) as a sentinel for human infectious disease, i.e. dogs being sick with or that have had exposure to disease-causing pathogens acting as a flashing warning sign for risk to the 2 legged animal (i.e. you, me and…girls-it’s time to stop with the screen time!). As is no real surprise, the idea of using dogs as infectious disease sentinels isn’t very common and per the article is even more radical for us Canadians (only 3% of the included studies, or if you prefer 4/142).

Animals have long been used as human risk sentinels, and as someone who spent much of my childhood in Flin Flon, Manitoba (https://en.wikipedia.org/wiki/Flin_Flon) the author’s use of ‘canary in the coal mine’ was a great way to consider (and re-consider) myriad ways animals have worked to warn us of threats to human health- be these environmental or infectious disease related.

In many ways dogs are the ideal sentinel for human health risk and I’ve written about this before on the Pets and Ticks website, while paraphrasing (parroting) Public Health Ontario’s Systematic Review on Companion Animals and Tick-borne disease (https://www.petsandticks.com/companion-animal-and-tick-borne-dis), which identified considerably more studies (n =44). For the very few of us who do research with dogs acting as sentinels, the human-animal bond and wealth of shared environment, e.g. dogs sleeping in the same room,+/- on the bed, and sharing a life full of things both of us (i.e. dogs and people) need (i.e. snuggles and all items unconditional), makes dogs the ideal (and admittedly just plain fun) research warning bell.

Most of the research (76%) identified by the review was on the use of dogs to estimate seroprevalence (blood antibodies in most cases) to certain pathogens that can cause infections, such as those spread by Ixodes scapularis (black-legged) ticks, most commonly Borrelia burgdorferi (the agent of Lyme disease), but also potentially emerging anaplasmosis, babesiosis and Powassen encephalitis. In ‘Our true north, Canada’, the researchers pointed out that using dogs to look for: 1) viruses like California serogroup viruses, Chikungunya and West Nile, 2) bacteria and rickettsia such as, Rickettsia and Ehrlichia spp., and 3) parasites, like the worm Dirofilaria immitis (canine heartworm), should be strongly considered due to disease emergence caused by our homeland’s increasing hospitality to ticks, mosquitoes and other disease vectors.

Finally, the study concluded with what most of us who do this type of research already know…in order to achieve study ‘do-ability’ a number of critical factors are non-negotiable. I’ve summarized these (and added a few) to create a ‘Top 10 Needs for K9 Sentinel Surveillance Studies” list:

1.    Be very clear on what you are looking for, i.e. what disease, type of disease emergence, and/or range of disease spread

2.    Do the study in an identified risk (or emerging risk) region

3.    Ensure you have study participants (sentinel units) such as veterinary clinics and pet-owners who will participate, i.e. no sentinels = no study

4.    If you’re looking for something new (emerging), start with naïve (negative for the bug) dogs and follow them over time and space (see #2)

5.    Hope (really hard) that you can repeat your sampling. That means relying on your people (participants and sentinel units) and trusting that they will enable continued study participation (study engagement) and repeat that for as long as the study lasts. This is a big ask.

6.    Allow the researcher (s) time, so as to actually ‘do’ the study.

7.    Allow the researcher (s) funding, so as to actually ‘do’ the study.

8.    Be pet-ethical. Never forget that these dogs have a very important job in many cases- to be a beloved companion. So, don’t do any testing beyond what they are already receiving as routine care from their dedicated veterinary clinic, such as an annual blood draw. Think of them like your own pets i.e. they are not ‘study subjects’.

9.    Save your samples- so that if something changes (or a new test or disease emerges) you can go back and look for it (whatever ‘it’ may be)

10. Work with your community of dedicated pet-owners and sentinel clinics- they know the dog best- and can provide a wealth of information reaching far beyond a blood test. This can help you sort out health concerns, risk factors (for the dogs and their people) and put things like travel beyond or between regions into correct data interpretation contexts.

Working with our canine protectors is not a new concept, but it can be a novel for some researchers and particularly funding agencies. The review also does a nice job (IMHO) of emphasizing that enhanced communication and collaboration between doctors of all species (veterinary and human), is looking more and more likely to be the way to identify, increase knowledge and stay safe from intruding infectious disease, particularly in Canada.

It’s heartening to see that research such as the Canadian K9 Lifetime Study or Pet Tick Tracker are regarded as illuminating (at least by researchers from the land of bagpipes, whiskey & Gaelic), and I’ve no doubt that dogs will continue to shine a Lyme-light on ground-breaking studies, that similarly helps their humans.

Autumn is coming. And lepto may be more likely...

As a native of the Canadian prairies, for much of my life I was oblivious to the glory of fall, and the wonder of cooler nights, warm (but not hot) days AND brilliant red, orange and yellow foliage. However, now that I live in a part of Canada with a fall season > 1.5 weeks, my thoughts turn to the colour yellow for a more sinister reason than 5-star Atlantic Canada leaf-peeping. 

Yellow is the colour I associate with leptospirosis, and it’s a rather nasty bug (bacterium) that can infect and cause a range of illness in dogs. Vets typically diagnose leptospirosis as kidney (urine) and/or liver (jaundice) disease...which is why (for me), lepto = yellow. The bacterium is formally known as Leptospira interrogans, and in dogs we usually think about 4 serovars (strains of the bug) as key: L. canicola, icterohaemorrhagiae, pomona and grippotyphosa.

Typically, lepto is shed in the urine of animals like raccoons, rats and other rodents. These wildlife hosts also frequently populate urban (city and suburbs) environments, (e.g. Toronto where I think a raccoon is running for mayor), and then urinate into puddles or other water sources that dogs splash or wander through, thus becoming infected.

Lepto’s also a bug we tend to find in geographic ‘hot spots’ in N. America, and there’s been a few publications (from the U.S.A.) indicating these higher risk lepto locations (links below). A number of articles also show an increased risk during specific seasons, such as in northern climes, where we tend to see more lepto in late summer/fall…hence the title of this post and my hope to increase awareness and reduce dogs getting sick. 

Lepto links:

Spatial and spatio-temporal clustering of overall and serovars-specific Leptospira microscopic agglutination test (MAT) seropositivity among dogs in the United States from 2000 through 2007. Gautam, et al. https://www.sciencedirect.com/science/article/pii/S0167587710001649?via%3Dihub

Hotspots of canine leptospirosis in the United States of America. White, et al. 

https://www.sciencedirect.com/science/article/pii/S109002331730059X

Seasonality of canine leptospirosis in the United States and Canada and its association with rainfall. Ward, et al. 

https://www.sciencedirect.com/science/article/pii/S0167587702001836?via%3Dihub

Lungworm 'step-dance' to your door

Lungworm 'step-dance' to your door

A Cape Breton ceilidh is a fabulous way to spend a summer evening- and we were lucky enough to take in a few on our recent trip around the trail. The step dancing at the ceilidh (and my 2 girls trying to replicate it) made me think of wiggly worms…and the group of those I frequently consider when on clinics seeing K9 and feline patients are lungworms. 

 

Lungworms are a broad category of parasite which can settle in the lungs (hence the name) of various hosts (e.g. dogs, cats), or for the very unlucky- migrate to other body systems. There are a lot of different kinds of lungworms to be aware of, and while some are found globally, varieties of lungworm can vary regionally. That’s important information dependent on where you happen to live or are travelling to- with or without your pet.

 

Since I spend much of my time in eastern or Atlantic Canada, my ‘Top 5 K9 and feline lungworms’ to consider as: 1) a cause of a disease, 2) to raise awareness for vets and owners, and 3) where possible- take steps toward prevention, includes:

 

1.   Fox lungworm (Crenosoma vulpis)- This worm used to be just in Atlantic Canada; however, in recent years cases have been found in Ontario. The main host (you guessed it) is the fox, which are plentiful here on PEI. Since fox are not that different from dogs, they can be infested, and disease can manifest as coughing. Dependent on where you live, prevalence can be high. In one study of coughing dogs up to 27% were infected: https://www.researchgate.net/publication/11370175_Lungworm_Crenosoma_vulpis_infection_in_dogs_on_Prince_Edward_Island

 

2.   French heartworm (Angiostrongylus vasorum)- This worm really likes to settle in specific spots within countries or geographic locations, e.g. Newfoundland, southern England, France. Clinical disease in dogs can be severe- fatal (e.g. effort to breathe, blood loss) or milder (e.g. cough, exercise intolerance). It’s a nasty one that’s been predicted to spread to other parts of N. America. https://www.ncbi.nlm.nih.gov/pubmed/21310537

 

 

3.   Cat lungworm (aleurostrongylosis)- Unsurprisingly, we think about this wiggler in cats or wild cats, especially those that hunt and eat snails, slugs, frogs, birds or rodents carrying the parasitic larvae. 

 

Here’s a nice review from parasites and vectors that gives some info on what to consider if your cat is acting off or shows any respiratory signs, e.g. cough, wheeze, or working to breathe. https://parasitesandvectors.biomedcentral.com/articles/10.1186/s13071-016-1671-6

 

 

4.    Eucoleus aerophilus/Capillaria aerophilla- This nematode (worm) is a globe-trotter i.e. found worldwide. Both dogs and cats can be infested, and the eggs are very difficult to kill once shed into the environment. Once again- cough is the concern in your pet, and the disease (and worm) looks to be emerging in various countries it’s not been seen before: https://www.researchgate.net/publication/24212877_Infection_by_Eucoleus_aerophilus_in_dogs_and_cats_Is_another_extra-intestinal_parasitic_nematode_of_pets_emerging_in_Italy

 

 

5.   Finally, rat lungworm…which is (or should be) a bit of an oddball worm to cause disease outside of rats. However, I couldn’t resist including 2 recent reports of disease due to this worm from a traveler-beware standpoint.

 

In China or the Pacific islands, be alert that centipedes may be infested with rat lungworm (Angiostrongylus cantonensis) which if consumed accidentally (or intentionally) can lead to meningitis in humans. http://www.ajtmh.org/content/journals/10.4269/ajtmh.18-0151

 

 

Another report from Hawaii has identified this worm as a cause of neurologic disease in humans (big and little versions) related to consuming raw or unwashed veggies contaminated with tiny slugs or snails infested with the worm: (http://www.promedmail.org/direct.php?id=20180818.5973796

 

 

Rat lungworm might be something to think about for those humans already planning travel far far away from the frigidity of the canuck winter and wanting a novel eating experience- or for those tempted to buy local and not washing the veggies (or anything potentially contaminated with slug or snail trails) thoroughly.

 

 

Parasites are fiddlin’ about everywhere, and while some (like many of the worms listed above) prefer to stick close to their geographic home-base… travel, pet importation and lack of awareness (and prevention where possible) can translate into worm wigglers establishing residence within your own pet- or you. As ever, upping awareness of what worms (and other germs) live where you do (or where you and your pet travel) and practicing simple hygiene dictums (wash your hands, wash your food, don’t eat poop) can reduce risk.

Tick talk simplified...s.v.p.

Tick talk simplified...s.v.p.

 

My favourite quotes tend to come from children’s books or from authors who write for children. One of my very favourites is from C.S. Lewis (author of The Lion, The Witch and the Wardrobe), “Don't use words too big for the subject. Don't say infinitely when you mean very; otherwise you'll have no word left when you want to talk about something really infinite.” 

Simplification (and removal of melodrama) eases comprehension considerably. One recent article delivers this ‘dial it down’ message through summarizing the progress (and ongoing challenges) in tick education and prevention for the general public. Primarily the ongoing struggle between alerting the public to the health risks posed by tick bites through education campaigns… and the discrepancy with this knowledge and awareness of risk and actual outcome on behavior change that reduces risk of tick attachment, e.g. applying bug spray, other forms of prevention. The publication also makes the point that utilization of the ‘KISS’ (Keep it simple…) principle continues to be the best method to dispatch information between groups- in this case between the general public and tick (and tick-borne) disease researchers.  

https://www.researchgate.net/publication/325384226_Progress_challenges_and_the_role_of_public_engagement_to_improve_tick-borne_disease_literacy

It’s a nice review on ticks and tick risk, and a great reminder for those of us within the scientific community (i.e. human and veterinary researchers/clinicians) that high priority should be placed on conveying information to the public in an easy-to-understand, succinct format, ideally with a visual component. Science communication is a very (infinitely?) important field and based on my re-read of this blog something I should probably continue to work on.

Citizen science...not a movie title.

Citizen science...not a movie title.

Citizen scienceis a legitimate form of research despite how it sounds, i.e. the term is not the title of a Spielberg film. The brief definition of citizen science (for those of us, like myself, who make use of this style of research), boils down to the general public participatingin scientific work in collaboration with established researchers. And, believe me when I tell you that it is nothing short of amazing to watch people (communities) come together to help drive knowledge forward. 

Examples of citizen science include projects like the Pet Tick Tracker (https://www.petsandticks.com) that use pet sentinel surveillance (i.e. ticks submitted by pet owners that they’ve found on their pets, e.g. dogs, cats, horses) to help identify tick ranges, and also whether new tick types (species) are beginning to set up shop in places they haven’t before. One example of that would be the lone star tick (Ambylomma americanum), which appears to be attempting to cross the bridge into PEI on a recent tick tracker map (https://www.wormsandgermsblog.com/2018/06/articles/animals/cats/tick-tracker-maps-june-2018/).

Another type of citizen science research is the Canadian K9 Lifetime (Lyme) Study, which was nicely summarized in a recent blog post on Scott Weese’s worms and germs: (https://www.wormsandgermsblog.com/2018/06/articles/animals/dogs/canine-lifetime-lyme-study/).

These types of studies are not for the ‘faint of heart’ researcher, as they tend to be labor intensive and difficult to obtain funding for. On the other hand, these kinds of projects yield information that is practical and useful on multiple fronts- and that is relevant for those of us who consider ourselves members of the general public, i.e. hold down a job, try to be kind, live life, +/- raise our children, and/or care for our pets and basically do the best we can day in and day out…. which also happens to be my definition of a citizen.

Stay tuned to this blog and https://www.wormsandgerms.com to learn how you (and your dog) can make a difference by working to improve K9 health.

I love puppies...

I love puppies...

I love puppies. However, somewhat ironically, in my day-to-day gig as a veterinarian it’s pretty rare that I get to see (much less snuggle) with them. There are a number of reasons for this, probably the largest one being that as an internal medicine specialist I don’t tend to see a lot of puppies or healthy dogs. In fact, most of the patients I (or my vet students) see tend to be sick, and more and more they seem to be ill with infections that are increasingly difficult to treat. 

Antimicrobial resistance (i.e. bacteria not being killed by antibiotics) is a problem in human and veterinary medicine. And while the focus (and burden) of this is frequently centred on human health care providers, the spotlight is on veterinarians as well. Where am I going with this you ask OR what does this have to do with puppies? (Besides the obvious awesomeness of puppies in general). Hang in there…

Antimicrobial stewardship is a topic that many people have never heard before, and even those of us who have can find the topic uncomfortable or just plain confusing. However, regardless of your definition of antimicrobial stewardship (or how many multi-syllable words you like to cram together), what it means is all of us taking the time to be more aware of things we can do to recognize that infection occurs (and worsens) when we forget to stop and think about the long-term effects of our choices (i.e. the stewardship aspect). And that’s true whether we are human health care providers, veterinarians, pet-owners, parents or just plain people. 

I think the other thing to recognize is that we all need to help each other be better about resistant infection-prevention (i.e. the antimicrobial or antibiotic choice portion) by accepting accountability for our actions. Resources that help with informing this include: Canresist (https://canresist.com), Do BUGS NEED DRUGS? (http://www.dobugsneeddrugs.org/wp-content/uploads/info-sheet-english.pdf), and AMMI Canada’s short and snappy ‘Symptom-free pee: Let it be’ (https://www.ammi.ca/?ID=127). These simple messages can help educate all of us to be more aware (and vocal) about things we may hear, observe or are told in our doctor’s office, veterinary clinic, at school, virtually any public place or at home. 

So, feel free to test out your awareness and commitment to stewardship (and my love of puppies) anytime this week (or next). An example might be to say “Michelle- Can you please wash your hands before you touch my dog?” And just watch me smile- and then head over to the sink so that I can enjoy the snuggle-fest AND respect your choice to help me keep your dog as safe as we both can.

June 21, 2018

Michelle Evason, DVM, BSc, DACVIM