Rural small animal clinic on Ometepe Island, Nicaragua

One important aspect that working in this environment brings forth is the opportunity to gain experience with diseases rarely seen in other countries. One such disease that was omnipresent on Ometepe Island was Ehrlichiosis, which is definitely of public health importance as it can infect both animals and humans. This is a great example of a vector-borne disease, in which the infection is transmitted from person to person (or animal to animal) by a vector, usually an arthropod like a mosquito or tick.

Canine patients with ehrlichiosis are often emaciated

Our patient was a young female dog that was brought up to the clinic for wellness care and inappetence. On physical examination, the patient was dehydrated, weak, emaciated and infested with ticks, especially around the ears. A more thorough examination revealed that all lymph nodes palpated were enlarged and that the dog was anemic as well.

Diagnosis of Ehrlichia was made by using an antigen SNAP test that allows us to look for other types of infections, such as heartworm and Lyme disease. Every patient seen at the clinic also had blood drawn to look for Ehrlichia microscopically and also assess platelet numbers for potential surgery and, in this dog, visual identification of the organism in a neutrophil confirmed the diagnosis.

Due to the severe emaciation and anemia, our patient did not go to surgery for sterilization and an antibiotic regimen consisting of doxycycline was started. In addition to antibiotics, the owner was given 6 months’ supply of flea and tick medications.

Our dog was severely infested with ticks

Ehrlichiosis can be caused by a variety of parasites of the Ehrlichia or Anaplasma families. Several of these can cause infection in both animals and people and all of them are transmitted through the bite of a tick vector. The type of ticks that can transmit ehrlichiosis varies depending on geography but most common vectors include the brown dog tick (Rhipicephalus sanguineus) or other ticks from the Amblyomma or Ixodes species.

In dogs, ehrlichiosis is commonly caused by Ehrlichia chaffeensis, E. canis and E. ewingii. These can affect several body systems and clinical signs include fever and enlarged lymph nodes (lymphadenopathy), however, polyarthritis, conjunctivitis, thrombocytopenia and hepatosplenomegaly can also occur. It is important to remember that other animals such as horses, cattle, sheep and even cats can also be infected by other Ehrlichia or Anaplasma.

In addition to a blood test for ehrlichiosis, we were able to identify the parasite in a neutrophil on a blood smear

Human ehrlichiosis can be caused by several of the same species of Erhlichia known to infect animals, including E. canis, E. ewingii and E. chaffeensis. In people, it appears that E. chaffeensis can cause somewhat of a more severe infection. Humans, just like animals, are infected through the bite of a tick and the disease can be characterized by fever, muscle ache, respiratory and neurologic problems such as ataxia and meningitis.

This disease highlights the risk posed by vectors like ticks that can infect animals as well as people. Vector-borne infections give us the chance to look at a true One Health paradigm for disease. Indeed, these infections cause disease in both humans and animals and the distribution of vectors like ticks (but also mosquitoes) is largely dependent on the environment. In fact, simply treating our canine patient for ehrlichiosis on Ometepe Island would have gotten the current infection under control. However, in a setting where ticks are very prevalent, it would be a mistake to forget about environmental factors that lead to infection in the first place. This is the reason why we gave as much topical preventive medication against ticks and fleas as we could with the hopes of reducing the number of ticks climbing on, and thus re-infecting, dogs. In a perfect world, the house and the environment where the animals (and people) live should also be treated to make sure ticks don’t thrive there.

A note on tick-borne diseases

Ehrlichiosis is just one example of a disease transmitted by vectors such as ticks and there are many others. Perhaps the most famous one is Lyme disease, which is present in both North America and Europe, however, different diseases can occur in different parts of the world. The Centers for Disease Control and Prevention (CDC) has a great list of which tick-borne disease are present in the USA as well as in other countries.

The brown dog tick can infest homes (image source)

One of the great misconceptions about ticks is that people are only exposed when they go into nature, when hiking for example. While it is true that most tick species are usually present in the wild, some species, like the brown dog tick (Rhipicephalus sanguineus) are known to establish themselves in houses and can cause some pretty severe infestations in people’s homes (one female tick can lay at least 2000 eggs in the environment…or in someone’s house).

This is why pets should always be on flea/tick preventives, even if they don’t usually go hiking with their owners. People who notice ticks in their homes should call exterminators to help treat the infestation. Furthermore, it is recommended that those who go hiking wear long pants and sleeves and check themselves for ticks after the hike.

Finally, I would like to, once again, remind readers about the effect of a changing environment on the distribution of vector-borne diseases. Global weather changes can cause higher temperatures and humidity, which leads to an increase in the number of vectors, but also their range. I have touched on that in a previous post, specifically regarding mosquitoes. However, ticks also benefit from these weather changes. A recent study has shown that due to higher average temperatures, Norwegian ticks can now be found in places where they traditionally did not exist.

More information on Ehrlichia and tick-borne diseases:

World Health Organization (WHO) – Vector-borne diseases

European Centre for Disease Control (ECDC) – Tick-borne diseases

Rabinowitz PM & Conti LA. 2010. Human-Animal Medicine. Saunders Elseviers ed.

I just had the opportunity to attend to the International Meeting on Emerging Infections (IMED), held in Vienna, Austria where I presented a poster on West Nile Virus (WNV) surveillance efforts in Southern California (click here to read my previous post on WNV monitoring in wild birds).

Ugandan artist’s rendition of the Ebola outbreak presented at the conference by a speaker from South Africa.

The event united over 700 visitors from 99 different countries and presenters shared their experiences and findings on various issues regarding infectious diseases in both animals and people. One of the themes that was highlighted across the board was the need for an appropriate educational component when fighting emerging infections, especially in developing countries. Viruses like Ebola for example, that can cause severe disease in those affected, can be transmitted from animals to humans, or between people, due to specific habits that are practiced in areas at-risk. Ebola is present in wildlife and several outbreaks in Equatorial Africa have been associated with hunting and consuming primate meat. As the animal is hunted and prepared for food, the virus, found in the primate’s blood, can enter the hunter’s body through scratches or wounds. However, the virus is also shed in the saliva and secretions and contact with these fluids is the main way that this disease spreads to others once an outbreak has started. This is why attending the sick without proper personal protective equipment can cause transmission of the disease. Unfortunately, Ebola is often fatal and family members or friends who prepare the body for burial can also become infected by such activities. The speaker  of this particular presentation emphasized on cooperation with local leaders in order to increase efficacy of control measures. One such example was apparent when the presenter discussed traditional Muslim habits of preparing a body for burial, which has to be done in a certain way but can expose people to the virus. One crucial step in implementing intervention methods was to meet with higher Muslim leaders in the region as they only could grant exceptions to these burial practices once they understood the circumstances. This is a perfect example of how trying to manage outbreaks in any country without taking into consideration the local culture can fail, even if responders have all the appropriate medical tools at their disposal. A lot of great work is done by USAID in Equatorial Africa in order to understand the drivers for emerging diseases like Ebola.

Covering jars collecting date palm sap is a simple and effective way to prevent contamination from fruit bat urine and therefore, human transmission of Nipah, as described by this presenter from Bangladesh.

Another clear example of how human practices can affect disease dynamics is Nipah in South East Asia. This is a virus that can affect both animals, such as pigs, and humans and is shed by  fruit bats from their saliva and urine. Just like Ebola, Nipah can cause grave disease in populations exposed. It was striking to see various presenters talk about their different experiences dealing with this disease and how neighboring countries can have big effect on the number of people affected because of the smallest changes in habits. As an example, in Bangladesh, the disease is concentrated in what is called the “Nipah Belt” and researchers have spent time looking at what are some of the causes for this increased presence of Nipah in this region. One of the most important factor was the consumption of raw date palm sap. In order to collect this delicacy, a shaved area on the tree trunk is made and a jar collects the sap. As it turns out, fruit bats are also fond of the juice and will drink from the jar, contaminating it with their urine or saliva. In neighboring countries such as Thailand, raw date palm sap is not as commonly consumed, and villagers also cover the collecting jars more frequently, leading to a reduced likelihood of transmission of Nipah. It is amazing to see how small interventions at the local level can greatly affect the life cycle of a disease and save lives.

Another risk factor for the transmission of Nipah to people is forest fragmentation, leading to increased contact between bats and people. One Health teaches us that the interactions between humans and our environment can greatly promote zoonotic transmission of disease, or even the apparition of new pathogens. Some of the presenters shared hard evidence of this relationship between health and the environment. A significant focus was put on some of the issues that can arise from loss of biodiversity. One may think that a decreasing number of wild animals may mean reduce chances of transmission of zoonoses. However, some  researchers presenting at IMED advocated that biodiversity plays the role of a buffer for disease and in effect dilutes pathogens across multiple species rather than concentrating them into a few species, which we can then enter in contact with. Similarly, loss of animal diversity and specifically predators can lead to an increased number of prey species that can be considered as pests such as rats, which can transmit diseases like plague.

Finally, we were reminded of some of the challenges that promoting public health and preventing diseases can generate. As  one presenter suggested, successes with disease prevention result in lack of illness, and therefore, it can be difficult for policy makers and the public to see the benefits of such programs. This is why it is important to maintain infectious disease prevention projects existent or we will likely face a come-back of some major infections that were controlled, and as such invisible, in the past while these programs were in place.

Overall this was a very interesting conference and I think participants were exposed to a lot of different challenges in disease prevention, but also new tools and ideas that can help us meet and overcome these challenges. I left Vienna with a new sense of motivation and I can only hope to attend the next IMED conference, held in April 2014 in beautiful Cape Town, South Africa.

Quick visit of beautiful Vienna…The Schönbrunn park, hunting grounds of the Kaiser where we can find the Gloriette, a ballroom built in 1775.

For more information:

International Society for Infectious Diseases (ISID)

ProMED-mail – A great way to receive updates on disease outbreaks (from ISID)

(Image source)

I had the opportunity to attend the 2^nd Zoobiquity Conference a few weeks ago, held at the UCLA Ronald Reagan University Medical Center. The main driving force behind this conference was Dr. Natterson-Horowitz M.D., who co-wrote the book Zoobiquity: What Animals Can Teach us About Health and the Science of Healing. In the book, the authors outline some of the fundamental similarities between human and animal health and what we can learn about medicine as a whole by broadening our perspectives to include all species.

The conference remained true to the subject of the book and brought veterinarians and physicians together to discuss health issues as they relate to each profession. The morning session was in the format of case discussions about various themes, such as cancer, diabetes, obesity and even bullying. Each panel had a representative from the veterinary as well as the human medical field, who presented their approach and challenges about the specific cases. Afterwards, presenters had a chance to sit down and foster a discussion on how this particular disease differs from species to species, or relates, and audience participation was encouraged.

One such example of this was evident during the discussion about osteosarcomas, from both a human veterinary perspectives. As I learned at the conference, human osteosarcomas can affect younger individuals and seldom metastasizes to the lungs. On the contrary, in the veterinary field, these bone tumors in dogs develop later in life and by the time a radiologic diagnosis has been made, the tumor has generally already spread to the lungs. Learning from these differences, physicians can look to veterinarians in order to understand better the pathogenesis involved in metastatic osteosarcomas. The Zoobiquity Conference moved beyond physical ailments and looked and mental wellbeing as well. It was eye-opening to see some of the striking similarities between bullying in children and aggressive behaviors between household cats. In both species, the victim is often an individual exhibiting submissive behaviors that are evident to the perpetrator.

The afternoon portion of the conference consisted of a guided visit to the Los Angeles Zoo where stations were set up demonstrating some of the concepts put forth by zoobiquity. These stations included comparison of echocardiographic appearance of heart diseases between gorillas and humans or lead ingestion in children and California condors.

Thanks to all the organizers of the 2nd Zoobiquity Conference, this was a great experience. (Image source)

It was incredible to see an audience filled with medical professionals from both the human and veterinary fields and the presentations did an excellent job at looking at medicine from a comparative perspective. So where does zoobiquity fit in relation to One Health? In my mind, zoobiquity refers to the similarities between medicines across species, whereas One Health is about how the health of different species and the environment can affect one another. The first step in promoting One Health is recognizing that health professionals can learn a lot by bridging the divide between species and by allowing veterinarians and physicians to sit down together and discuss similar cases, and the Zoobiquity Conference did just that.

For more information about Zoobiquity:

Zoobiquity website

It’s nice to get back out there and do some more international work. After all, this is globalhealthvet and I was looking forward to gain new experiences promoting veterinary public health abroad. I got exactly what I wanted a few weeks ago when I went to Nicaragua, on a student-led initiative to promote veterinary care on Ometepe Island.

This trip was organized by veterinary students from the International Veterinary Student Association (IVSA) chapter at Oregon State University for the 5^th consecutive time and this year, the group included 30 veterinary students and 8 veterinarians.

Ometepe Island, which is on Lake Nicaragua, is home to 35 000 inhabitants who rely heavily on agriculture for survival. In this rural environment, there can be limited access to veterinary care and a large part of the animal population has not received basic treatments. After taking a ferry to the island, the group was driven in small buses to Hacienda Mérida, which is where the clinic was set up. It was obvious from the ride through the island that people of Ometepe were living in remote conditions and that they did not always benefit from amenities such as telephone or paved roads. This is has a strong impact on health of both the people and their animals as medical care may not be readily available.

Ometepe Island, with its 2 volcanoes: Concepción (left) and Maderas (right)

The trip lasted for 7 days and the clinic was set up in a shed on the hacienda’s premises. Students were responsible for bringing supplies such as medications, centrifuges and microscopes. Fortunately, a lot of the supplies from previous trips was stored at the hacienda.

During the 7-day trip, a total of 774 patients were treated: 272 small animals for wellness exams/90 surgeries; 159 large animal patients/17 surgeries; 343 animals seen on farm calls by the mobile unit

Once up and running, the clinic consisted of several different stations. Personnel at intake was responsible for triage of patients as well as basic history. Small animals and their owners then moved on to wellness examinations, performed by students. There, the patients had their blood drawn and basic medications were given depending on abnormalities found on physical examination. Every animal also went home with a 6-month supply of deworming medications as well as flea/tick preventive. Blood samples were analyzed under the microscope for proper platelet numbers (a sometimes challenging job, as the humidity degraded the slides rapidly) and several SNAP tests were available to diagnose blood-borne pathogens such as heartworm or Ehrlichia. If patients were deemed healthy enough for surgery, they moved on to the induction station where all the proper medications were prepared for the upcoming operation. Surgeries were performed the same day and patients went home after recovery. This was very much student-led and as veterinarians, we were there to provide advice to students and help out if needed.

There was also a significant large animal aspect to this work and farmers would bring donkeys, horses or pigs to the clinic for treatments and surgeries. Finally, a mobile team was also able to travel throughout the island and provided a unique way to care for animals that were unable to come to the clinic, usually cattle herds.

Veterinary students performing wellness examinations

On the small animal aspect, most patients presented with severe malnutrition, emaciation, intestinal parasites as well as fleas and ticks. Our canine patients often had generalized lymphadenopathy, which can be a sign of underlying infections like Ehrlichia or Leishmania, both present in this region. Due to the limited diagnostics available, a specific cause for disease was not always evident however, animals requiring antibiotic treatment were given appropriate medications. It is likely that the patient’s poor nutritional condition exacerbated some of the underlying diseases that they may have had and we were able to provide people with nutritional supplements for their animals. It is also important to remember that most infectious diseases seen during this trip were zoonotic, and treating the animal definitely helped reducing the chances of human infection. In total, 90 surgeries were performed, mostly spays & neuters in dogs and cats, although other procedures included an abdominal hernia repair in a puppy or an enucleation in a chicken (all successful, great job students!).

On the large animal side, the focus was also on parasite treatment and prevention, but also surgeries like equine and porcine neuters. The mobile team also performed field treatments and pregnancy checks in cattle herds.

The mobile unit allowed us to treat cattle herds throughout the island

The students did an amazing job organizing this trip to Nicaragua and showed impressive ability to work in conditions that can prove challenging (which included an earthquake during the clinic). This trip represents a great opportunity for them to practice their skills with a hands-on approach and recognize the impact of veterinary medicine in developing countries; they will no doubt make great veterinarians.

Working in remote areas of Nicaragua, but also Peru and Morocco, I have seen the impact of neglect on the health of animals. It is important to remember that in a country where people are struggling to survive, promoting animal health does not always take

Flyers I made about leptospirosis & taeniasis - Community-specific education should be a key part to any public health program in developing countries.

precedent. It is obvious that principles of One Health in these places go beyond the management of zoonotic disease. People depend on their animals for survival and poor conditions or disease in a herd of cattle can greatly impact revenues of the farmers, and thus their health. Therefore, a crucial part of working in the developing world is education. Veterinarians and other health professionals should educate people about the impact of animal health on their own health, whether it is about zoonotic diseases prevention or promotion of healthy food animals that will be able to produce more for the farmers.

It was great to have the opportunity to steer the public health discussion (speaking Spanish helps…)

Following this philosophy, our trip to Nicaragua had a strong educational component and I was asked by the organizers to participate in a public health session for those attending the clinic. Working in a place with a different culture and language can sometimes create barriers when trying to explain public health concepts and therefore visual aides can prove to be very helpful. To this end, the students and veterinarians had designed a couple of posters outlining these concepts and I designed informational flyers about 2 diseases commonly seen in Nicaragua. The discussion was very well received and had great participation from the attendees.

This trip is a great example of how a motivated group of people can organize a successful and long-lasting global health program that has a big impact on a local community. This was organized by veterinary students from OSU, who were able to secure funding and supplies, and has been successful for the past 5 years. I had a great experience during this trip, learned a lot and I definitely hope to be able to participate in the next trip in 2013.

The entire Nicaragua team! Thanks to Hacienda Mérida and all the students from OSU for making this experience so awesome (Image source)

Mosquitoes such as this Culex sp. act as vectors for West Nile Virus infection in animals and people (Image source)

One great example of this is the disease West Nile Virus (WNV) and its accidental introduction in the Americas. WNV is a present worldwide and is transmitted by mosquitoes such as Culex spp.

West Nile virus was first seen in the USA in 1999 in New York City, where health officers noticed a new type of encephalitis spreading through the city. While they were trying to diagnose the disease, wild birds on the premises of the Bronx Zoo were dying in large numbers. This sounded the alarm for the veterinary pathologist at the zoo who collected samples from the dead birds and tried to have them analyzed. The veterinarian was turned down several times as most authorities thought that she was dealing with an “animal-only” problem which was unrelated to the outbreak in the human population. However, her samples were tested by the Army and West Nile Virus was found to be the culprit of both the animal and human outbreak. It took the virus about 5 years to spread from the East Coast to the West Coast of the USA, disseminated by mosquitoes and bird reservoirs. It was later speculated that the virus entered the country by boat through introduction of mosquitoes that laid eggs in old tires that accumulated some standing water.

Life cycle of West Nile Virus (Image source)

In people, the syndrome is usually mild and some individuals will not even notice they’ve been exposed, others will have a mild flu-like disease and recover on their own. In about 1% of cases, however, the virus can invade the brain and cause severe neurologic symptoms which can be life-threatening. This disease is called Neuroinvasive West Nile and affects more commonly those who are immune-suppressed such as the elderly or people suffering from chronic diseases.

A wide range of animal species can suffer from WNV infection as well and it is commonly seen in birds. Some birds do not suffer from the disease and act as reservoir, in which the virus multiplies and spreads through the bite of mosquitoes. Other birds, especially crows, are very susceptible to illness and will often suffer from sudden death (as seen in the Bronx Zoo in the original outbreak). These birds are the ones that people use the most to monitor WNV in the environment, and an increase in crow deaths in summer months is often associated with West Nile activity. Other animals that can be affected by the disease include dogs, where the infection is somewhat mild and horses, in which the disease can be much more severe. In equids, infection often leads to severe neurologic signs such as ataxia and can lead to death. Because of this, a vaccine against WNV in horses has been developed and is widely used. There is also some evidence that, at least in birds, the virus may be transmitted from one animal to another by direct contact, since it is present in oral secretions; however mosquitoes remain the most common mode of transmission.

Dead crows in Los Angeles County can be reported to the County’s Veterinary Public Health Program. The mouth of the bird is then swabbed and tested for WNV antibodies.

West Nile Virus has now a pretty strong hold in the Americas and eradication methods would be difficult to put in place. Some insist that the presence of the disease has become normal and that monitoring for the disease has become useless, as we already know the virus has implanted itself. However, as the current outbreak in Texas shows, WNV has made a comeback and several people have been affected, including 87 deaths (as of this post’s publication date). This shows that there should not be any laxity in zoonotic disease surveillance. One of the aspects that make WNV an interesting model for One Health is the relationship between human and animal infections. Experimentally, a zoonosis will affect animals first and then spread to people. West Nile Virus follows this pattern almost exclusively. As we enter hot summer months such as August, we usually see a sharp increase in cases in animals such as crows as well as horses, followed by an increase in human cases about a month after. Monitoring the impact of the disease in wildlife will surely give us an idea of how it will affect human populations later in the season so that health professionals can be ready for it.

I am taking an active participation to this disease surveillance working in public health in Los Angeles County and one of my duties is to routinely test for West Nile in dead wildlife such as crows. The test used is an antigen test, which enables us to determine if the animal was infected at the time of death. As far as this season, I have seen a sharp increase in positive birds since the beginning of August but overall numbers of positive birds is less than it was at the same time in 2011. Other parts of California, however, have reported increase in both animal and human cases.

The Vectest is an antigens test used to detect WNV infection in crows. Two of the three birds tested on this picture were positive – A dark red line represents the control and a faint red line below it (red arrow) shows the positive result.

In order to reduce likelihood of contracting West Nile virus, these guidelines should be followed:

• Wearing long-sleeves shirts during times of increased mosquito activities (dusk & dawn)
• Making sure there is no standing water around the house where mosquitoes can breed
• Horse owners should also vaccinate their animals for protection during peak WNV activity, under the guidance of a veterinarian

Global West Nile virus distribution in 2011. Since its introduction into the Western Hemisphere, West Nile Virus is considered to be present worldwide, unfortunately, not every country has the ability or resources to monitor and report the disease to public health organizations (Image from the OIE’s World Animal Health Information Database – WAHID)

Finally, there is no arguing that there are changes in our weather pattern. This may lead to an increase in rainfall or more extreme temperatures. Mosquito distribution depends greatly on these factors and some studies have shown that a small increase in average temperatures can lead to a wide spread of diseases classically thought to be tropical in nature, such as Dengue Fever or even Malaria (study).

More information on West Nile Virus:

CDC – West Nile Virus

Center for Food Security and Public Health – West Nile Virus Technical Sheet

Microbe World – One Health and the lessons learned from the 1999 West Nile Virus Outbreak

Rabinowitz PM & Conti LA. 2010. Human-Animal Medicine. Saunders Elseviers ed.

World Organisation for Animal Health (OIE) – West Nile Fever factsheet

1. In your opinion, what are some reasons that cause dogs to attack or bite people?

“Dogs usually bite because they are feeling threatened or frightened.  In some cases, a dog may feel threatened because an approaching person is unfamiliar, or appears strange in some way.  In other cases, a dog may be frightened by the behavior of a familiar person.  A dog may also feel nervous for reasons completely unrelated to the humans around, such as strange things or animals in the environment.

Unfortunately, people often create situations where a bite is more likely by ignoring warning signals the dog is giving (see Question 3 for more on warning signals).  People can also be bitten due to what is called redirected aggression, which means the dog is already extremely agitated and bites a person more or less by accident simply because the person is nearby.  (For example, when two dogs are involved in a fight, if a person steps in to separate the dogs, one or both of the dogs will often bite the person, without appearing to intend to do any harm to the person.  Unfortunately, damage from bites like this can be very severe.)

The common factor in most bites, whether to a person or to another animal, is that the dog feels so uncomfortable about a situation that he feels he has no choice but to use his teeth.

2. What are some mistakes that people make around dogs that result in a bite?

The biggest mistakes that lead to bites are cornering dogs and ignoring signals that a dog is feeling uncomfortable.  Another mistake that can lead to bites is punishing a dog for behaving in an anxious manner, or for giving obvious warning signals.

Let’s start by addressing the first topic – cornering dogs.  Dogs, like most animals, choose between fight and flight when they are scared.  When a dog is cornered, flight is not an option, so the dog more or less has to choose “fight” – which in many cases means “bite.”  It’s never a good idea to corner a dog, even if the dog seems completely relaxed.

The good news is that most dogs give a lot of signals saying “back off” before they actually go as far as biting.  The bad news is that many people do not know how to read those signals, so a dog may be forced into a position where the dog feels biting is the only option. (See the answer to Question 3 for tips on how to read dogs better.)

Another common mistake people make is punishing a dog for being scared or anxious.  This actually strengthens the dog’s impression that a situation is dangerous; not only is something scary around, but now the dog is being punished by a human she trusts.  This makes the dog more likely to bite, both in the moment, and the next time the same kind of situation comes up.

Another way that people accidentally make dogs more likely to bite is by punishing the warning out of the dog.  The most common mistake people make in this regard is punishing a dog for growling.  A growl is basically a dog’s way of saying “I am uncomfortable.  Please let me out of this situation, or I may have to bite.”  When you punish a dog for growling, there are two likely outcomes, both of which are bad.  The first is that the dog will immediately bite.  The second is that the dog will learn to suppress the growl, so the next time the dog will not growl first to say “please stop,” but will simply bite right away instead.

In other words, when you punish a dog for growling, you are making it more difficult for the dog to communicate without using her teeth.  When a dog growls, back off immediately.  Then try to figure out what made the dog so uncomfortable (so you can avoid that situation in the future, at least until you have done some training, as discussed in Question 4), and remember to mentally thank the dog for warning you, instead of simply going straight to biting.

In summary, here are some tips for avoiding bites:

1. Avoid cornering dogs.
2. Learn to read warning signals from dogs (see Question 3).
3. If a dog growls at you, back off immediately.
4. Never punish a dog for acting nervous.
5. Never punish a dog for growling (you don’t want to punish the warning out of the dog).

3. How can you tell if a dog is scared/anxious or ready to bite?

There are many signals dogs give when they are nervous.  The list of behaviors seen in these situations is quite long, so I will only include the most common ones.  Here are some things to look for:

• Yawning when the dog is not tired
• Licking the lips (or just flicking the tongue in and out of the mouth) when there is no food around
• Panting even though it’s not warm
• Raising one paw and holding it up tentatively
• Turning the head away
• Curving the body or turning the whole body away
• Blinking rapidly
• Lowering the head
• Tucking the tail between the legs
• Trying to move away from a situation.
• Freezing in place (standing very stiffly)
• Staring
• Raising of the hackles (this is when the hair on the back of the neck, and sometimes even the whole spine, stands up)

When dogs are cornered or otherwise forced to remain in a scary situation despite giving the signals mentioned above, they may escalate to more obvious signals, such as the following:

• Drawing their lips back to show their teeth
• Flattening their ears back
• Growling
• Snarling
• Lunging
• Air-snapping (biting the air with a loud clap of the jaws)

Note that if a dog lunges and air-snaps at a person, that is actually a warning.  The dog did not try to bite and “miss”; dogs have very good control of their jaws.  An air-snap means the dog made a conscious decision not to bite.

All of these signals are warnings from the dog.  The dog is telling you the situation is too much for him, and that a bite may follow.  These warnings need to be taken seriously, even when the warning is relatively subtle (e.g., a lip lick).  In fact, noticing subtle warning signals is the best way to prevent a bite.

The video at the following link shows examples of some of the more subtle signals dogs send, and can be a helpful tool for learning to identify the types of behavior that indicate a dog is anxious or scared.

Click on the image to see the video

4. What are your recommendations on how to behave around a stressed/aggressive dog?

The number one consideration must always be safety.  In general, if a dog is giving signs that she is anxious, it’s a good idea to back away from the dog calmly and slowly.  If a dog has flattened her ears and is growling or snarling at you, you should also try to put a physical barrier (such as a door) between you and the dog if possible.  This is especially important if the dog involved is a stranger to you, and is loose.

If the dog is only showing subtle signs of anxiety, such as lip licking or turning away, it may be enough to give the dog an opportunity to move away to a distance that is comfortable for her, but you have to be sure there is enough room between you and the dog to allow her to escape the area if she chooses.

If the dog you are dealing with is your own dog, after creating some distance between you (or allowing the dog to create distance), make a mental note of what made the dog so uncomfortable.  Then find a trained professional who uses force-free methods to help you come up with a training plan that will help your dog learn to feel more comfortable in that type of situation.  Here are some good online sources for trainers who can help you teach your dog to feel more relaxed in situations that used to scare her:

• http://positively.com/dog-training/find-a-trainer/
• https://www.karenpryoracademy.com/find-a-trainer
• http://www.petprofessionalguild.com/
• http://www.trulydogfriendly.com/blog/?page_id=4
• http://www.peaceablepaws.com/referrals.php

5. Any other recommendations for dog owners?

Be proactive! Teach your dog to feel comfortable in a wide range of situations.  An excellent way to do this is to give your dog treats in new situations, so that he learns to expect good stuff whenever something strange happens.  The more you practice this, the more your dog will learn to handle a variety of situations calmly.

If you are dealing with a strange dog, or one you don’t know very well, keep in mind that dogs, like people, take time to make friends and develop trust.  Your own dog may not mind if you corner him accidentally, but a dog who does not know you well may find that frightening.  Similarly, a dog may not mind a hug or a kiss from his person, but a hug or kiss from a stranger can seem very threatening (imagine how you would feel if a perfect stranger walked up to you on the street and gave you a big hug and kiss).

I’d also like to point out a distressing statistic: Children nine years old and younger are bitten more often than any other age group.  Most of these bites could be prevented with careful management and education.  If you have children or get lots of child visitors, be sure to supervise carefully any time children are around a dog, even if the dog is generally happy to hang around with children.  Give dogs periodic breaks from interactions with children (who sometimes nag dogs), and watch dogs for signs of stress when they are around children.

Never leave a child unsupervised with a dog.

It’s also important to teach children that dogs are not toys, and that they need to be treated gently and respectfully.  Explain to children that dogs don’t particularly like hugs and kisses – and that even if their own dog is willing to tolerate these things, someone else’s dog might not like it.  In addition, instruct children to stand perfectly still, with their hands folded together, looking at the ground, if a strange dog runs up to them.  Most dogs are excited by screaming and movement, and a quiet, still child is in much less danger of being bitten than one who is squealing and running around.

Finally, whether you are dealing with a dog you know well or a strange dog, remember that you catch more flies with honey than with vinegar.  Kindness, praise, food treats, and toys are good ways to make friends.  Yelling, intimidation, and physical punishment are not.  Dogs are armed with very powerful weapons (their teeth), and scaring them using threats or violence is likely to get you bitten.  If you treat dogs with respect and kindness, they will generally return the favor.”

- Thank you very much Irith for this great Q&A! This is very useful information to understand the issue of dog biting from the dog’s perspective. Hopefully this will help reduce dog bite incidence, especially in children.

One way to do that is to bring all stakeholders together and work together to address specific health issues that need to be changed. The 2020 Healthy Pets Healthy Families (2020 HPHF) coalition, aims to improve several health-related issues using an evidence-based perspective. Anchored in a One Health approach, this task force brings leaders from various backgrounds including animal, human and environment for a collaborative effort to improve public health. This coalition is inspired by the Healthy People initiative, a model that has been in place since the 1980s, and meets quarterly to discuss their progress.

The Coalition has identified 7 focus areas, or specific issues, that will be addressed and improved. These are:

• “Pet Obesity: Pet obesity is skyrocketing, just like with people. What can help? Walking the dog! Studies show that walking the dog helps people get the recommended amount of exercise. By exercising together, owners and their pets can get healthy.
• Second-hand smoke: Pets can develop cancer after being exposed to second hand smoke. They can become ill after accidentally eating cigarette butts. A recent study supported the idea that educating smokers about the risk to pets may motivate them to quit.
• Spay-Neuter: Pets that are spayed or neutered have a reduced risk of certain cancers, and are less likely to roam, be hit by a car or bite someone.
• Vaccine preventable diseases: By increasing pet vaccination, we not only protect pets from these diseases, we also reduce the financial and emotional costs that these illnesses inflict on the community.
• Disaster Preparedness and pets: Preparing the family pets for disasters helps start the process of preparing the whole family.
• Bite Prevention: Approximately 2% of the population is bitten every year. Most animal bites can be prevented.
• Zoonotic Disease and Parasite Prevention: Zoonotic diseases are those transmissible between people and pets. Approximately 60% of the pathogens that can infect people are zoonotic. Pets owners can take many simple steps to protect themselves and their pets. Keeping a pet free of fleas, ticks and other parasites, protects not only the pet, but the family and neighborhood, from a variety of diseases. Pet owners that pick up the poop safeguard the community from contamination.” (Source: 2020 HPHF website)

At this early stage in the coalition, the goal is to gather data from various organizations that can be tracked in order to measure positive changes at the end of the decade. The task force will also create a public document outlining the scope of the problem and give more background information on 2020 HPHF; this publication will be available in December 2012. The next steps include establishing intervention strategies for each focus group that will take place over the next 8 years.

The 2020 Healthy Pets Healthy Families brought together veterinarians, physicians, animal behaviorists, professors from Western University and various other parties interested in improving both animal and human health.

Stay tuned for more developments on this exciting effort which applies One Health principles for the benefit of animals and people alike.

Dr. Robertson’s presentation on the veterinary perspective of animal hoarding generated a lot of interest from the audience.

There are several concerns related to hoarding, including animal abuse or neglect and public health issues for the people involved. Animal abuse is illegal in the USA and perpetrators can be prosecuted if found guilty.

Hoarders of animals often have the feeling that, by adopting dogs and cats, they are saving them from harm and providing them with a better life. However, the number of animals in a house can become so high that owners may not be able to keep track of all of them anymore and the pets themselves may have little access to food/water, or veterinary care.

This can lead to situations of abuse/neglect, in which animals become emaciated, malnourished and have chronic diseases. This is exacerbated by the fact that hoarders can be reluctant to accept the unhealthy condition of their pets, in spite of the clear evidence. Unfortunately, many of these animals need aggressive treatment to survive such conditions and in some extreme cases, they may even die inside a house without the owner realizing it or willing to give them up. Furthermore, this neglect of the animals’ condition can often lead to a self-neglect of the hoarder’s own health status.

One of the main threats to public and individual health related to extreme hoarding includes threats caused by zoonotic diseases. As mentioned previously, animals can be unhealthy, which is often reflected by heavy flea or tick infestation. These vectors can carry diseases such as cat-scratch disease, plague or murine typhus capable of infecting the pet owners themselves, and also spill over to neighboring houses.

The environment inside the house can also be a source of danger through several ways. Firstly, extreme hoarders are often overwhelmed by the sheer number of animals and cannot keep up with maintaining a clean house, which can lead to a state of squallor. As a result, animal urine or feces can accumulate. High urine levels lead to increased ammonia in the air, which cause (at very high levels) direct damage to the organism, such as irritation of airways, pulmonary edema or coughing. Furthermore, this squalor is also significant health threat by reducing safety in the house or causing potential fire hazards when windows and doors are covered for example.

A panel of different stakeholders including the Fire Department, law enforcers and mental health professionals came together to discuss their approach to hoarding during a case discussion.

This hoarding forum touched on several important points regarding the hoarding of things and animals. When it comes to animals, one commonly used definition of hoarding given by Dr. Robertson includes:

• Failure to provide for the animals
• Inability to recognize effects of this failure
• Denial or minimization
• Obsessive persistence

Unfortunately, there is a high rate of recurrence of hoarding and very few success stories of long-lasting resolution. Therefore, it is important to understand and address the complex underlying problems and potential causes that may lead some people to become hoarders, such as psychological issues like depression, loneliness or low self-esteem. Some attendees advised for a step-wise approach for cleaning a hoarder’s house, focusing on following safety regulations and guidelines, which may lead to more compliance. This forum re-iterated the need for a One Health strategy if we are to successfully manage animal hoarding situations. Alongside veterinarians assessing animals’ health, the human component of hoarding must also be addressed and mental health professionals must be part of a multidisciplinary team leading to a long-lasting beneficial relationship with hoarders, who are victims themselves of the condition.

More information:

Hoarding of Animals Research Consortium

Oakley B, et al. 2011. Pathological Altruism. Oxford University Press Ed.

Shelter Strategies

The “Five Freedoms” commonly used to assess animal welfare, neglect or abuse

Every dog can bite (Photo source)

Much of the reaction to dog bites have been the implementation of breed-specific legislation with the intent to reduce the number of large dog breeds such as Pit bull-type dogs or Rottweilers (breeds most often targeted by such legislations). While it is logical that bigger dogs can inflict more severe bites, research has shown that such legislations do not address the underlying causes of dog bites – managing and understanding dogs’ behaviors. As it turns out, every dog can bite, and a special report from the Journal of the American Veterinary Medical Association (JAVMA) from 2000 has linked about 30 different dog breeds to about 200 fatal dog attacks between 1979 & 1998. These included Dachshunds, a Yorkshire terrier and a Labrador retriever. The authors further mention that breed-specific legislations do not address the fact that a dog of any breed can become dangerous when trained to be aggressive. Another limitation of such legislations is that identifying dog breeds is not as easy as one may think. In fact, experts can often disagree on what makes up a specific breed and due to extended cross-breeding, DNA testing can yield a myriad of results that does not necessarily reflect the animal it came from, as shown by this study. For example, some of the most commonly targeted dogs include “Pit bulls”. As it turns out, “Pit bull” does not officially refer to a breed but rather a loose description of characteristics that a dog may have, which is why the official term is: “Pit bull-type breed”.

Breed-specific legislation do not address the underlying issues of dog aggression – mismanagement of dogs behaviors. This dog is a former victim of dog fighting. (Photo source)

In fact, the 2001 AVMA’s Canine Aggression Task Force warns that isolating and targeting a few breeds deemed dangerous can lead to a false sense of accomplishment when it comes to reducing severe dog bites, because it does not address the reasons behind dog aggression. Other experts such as the American Humane Association argue that breed-specific legislations are difficult and costly to enforce and can have unintended consequences such as black-market or indiscriminant breeding of affected dogs (after all, breeds most involved in bites are the most popular ones). So what should we do to reduce dog bites to people? In order to provide an appropriate alternative to breed-specific legislation, let’s take a closer look at the problem.

The situation in the USA

The first piece of data to consider is that the United States, as of 2001, is the country with the most pet dogs/people, with 53 million pet dogs nationally. This creates an environment where there is a high rate of contact between people and dogs, which can be a risk factor for being bitten.

In fact, the CDC reports that about 4.5 million Americans are bitten every year, and 1/5^th of these injuries require medical attention. These numbers reflect the scope of the problem in the countries like the USA. However, in order to properly address this issue, it is important to look at the populations at risk. Is everyone equally affected by dog bites or are there specific groups that public health officials need to focus their attention on? A closer analysis of the problem shows that half of bite victims are children under 12 years old. Another group particularly at risk is the elderly, specifically those 70 years old and over; even if they represent only 10% of those bitten, almost a 4^th of these bites can be fatal.

Kids are at higher risk of being bitten by dogs. Proper dog training and monitoring children’s interaction with dogs is essential to prevent bites. (Photo source)

Another important variable to look at is the background of the bite itself. It is indeed interesting to see in the previously mentioned JAVMA study that 58% of the people involved were bitten by an unrestrained dog in their own property.  What stands out from this study is that a great majority (75%) of dog bites were done by dogs that victims knew and inside their owner’s homes. Finally, the cost of dealing with dog bites can be significantly high, and the insurance industry in the USA has paid more than $ 1 billion in dog-bite claims annually.

Furthermore, bite statistics also show that the great majority of dogs involved in fatal attacks were males (about 92%), of which 94% were intact (not neutered). This suggests an important behavioral component that relates adult intact male dogs to the tendency of biting.

Los Angeles County is a county of about 10 million residents, there is a high rate of interaction between people and dogs. In fact, dog bites to people have increased between 2006 and 2009 in one report and LA County is one of the US’ top locations for dog bites. This is why bites are one of the main focus area of the 2020 Healthy Pets Healthy Families initiative (Stay tuned! – I will talk about this program and my involvement with it in further detail in an upcoming post).

This work consists of managing bite reports sent by bite victims or clinicians, which serves several purposes. The 1^st reason why it’s crucial to report all dog bites to local Department of Public Health is to get a better understanding of the issue in the county. As I’ve mentioned previously, dog bites in LA County have increased. Does this mean that more dogs are biting people or that more people are reporting bites? Only with the most complete data can officials truly understand the scope of the issue and focus their attention on specific groups or areas that are at higher risk.

The 2^nd reason why reporting bites is crucial is for rabies prevention. The veterinary staff at VPH puts a lot of effort in following through on each bite report to make sure the animal is properly quarantined and monitors if there are any signs of the disease. While rabies in dogs has become very rare in LA county, the severity of the disease warrants extreme precautionary measures to make sure people are not exposed (For more information about rabies, check out my previous post).

Recommendations

If breed-specific legislation show mixed results in protecting people from dog bites, what are actual recommendations that can help address the problem? Looking beyond such legislation, the most significant factor to look at is addressing behavioral factors…of the dog but most importantly people. Indeed, it is the belief of many experts that many bites occur from our lack of understanding of dog behavior, especially fear, and our inability to recognize warning signs that a dog is about to bite.

This dog exhibits typical fear behavior and may bite if approached. (Photo source)

There are many recommendations on how to avoid dog bites, but most of them revolve around a couple of main themes: being aware of the dog’s language and appropriate dog training and ownership.

Teaching pets submissive behaviors like rolling over are great ways to establish the owner as dominant and reduce dog aggressivity. (Photo source)

Such recommendations include:

-          Consult a veterinarian or professional before getting a dog – Many dogs have different personalities or needs. For example, a dog with a lot of energy can become frustrated and have unpredictable behavior if that need is not met. For these dogs, frequent exercise or outdoor activities is recommended.

-          Socialize & don’t abuse pets – Owners that don’t train their dog are not in control when a risky situation arises. Also, puppies who engage in “play bite” can grow up to become biters as they have not been taught otherwise. Furthermore, a dog that is abused will be afraid and this fear of people will translate into aggression.

Puppies often engage in play-biting. However, it is the owner’s responsibility to properly suppress such behaviors as the dog gets older (Photo source).

-          Supervise children when around dogs – As previously mentioned, children are highly affected by dog bites. Kids should be taught appropriate petting behaviors and be monitored during interactions with dogs.

-          Remain calm around an unfamiliar dog – Running away or trying to challenge an unknown dog can cause the dog to attack.

-          Do not try to touch a dog when it’s eating, sleeping or looks injured – Many dogs will feel threatened by people approaching them if they are injured. It’s not aggression; the dog is simply scared and trying to protect itself.

-          Spay/neuter dogs – As demonstrated by the figures above, a large number of fatal bites were inflicted by intact male dogs. These dogs have higher levels of testosterone and are more prone to dominant behaviors such as aggression. Likewise, intact females can attract roaming male dogs and may also bite when protecting their young.

Note: Impact in developing countries

The situation in developing countries is somewhat different and the threat of rabies is still very present. In fact, two of the most recent rabies fatalities (as of this post’s publication date) came from individuals exposed to rabid dogs in India and the Philippines. However a dog bite can be fatal in other ways, as not everyone in developing countries have access to appropriate medical facilities where bites can be treated aggressively. In this context, additional focus should be on stray dog spay/neuter & vaccination programs.

Stray dog in Peru.

For more information & recommendations on dog bites:

American Humane Association – KIDS: Kids Interacting with Dogs Safely

American Veterinary Medical Association – Dog Bite Prevention

Los Angeles County Departmen of Public Health, Veterinary Public Health – Dog bite Prevention

National Canine Research Council – Breed and Behavior

Veterinary Partner - Defensive Dog Behavior, Child Safety with Dogs,

Voelker R. 1997. Dog bites recognized as public health concern. Journal of the American Medical Association. Volume 277, Issue 4, pp.278-280.

usda.gov

Last week (April 24^th, 2012), a case of Bovine Spongiform Encephalopathy (BSE) was identified in a single animal in Central California.  This case, recorded in a dairy cow, is the 4^th ever case in the USA and was discovered through the USDA’s BSE Surveillance Program, which is a very stringent system allowing officials to detect the disease at very low levels. The USDA is still investigating the case but the appropriate measures have already been taken, and the affected animal did not enter the human food chain, therefore preventing any spread to people. Furthermore, the affected cow’s progeny has been tracked down and is currently being tested for the disease and the dairy farm where the animal originated is under quarantine. The Department further emphasized that beef is still safe to consume.

The disease, commonly known as Mad Cow, is caused by abnormal molecules called prions that, once ingested, travel to the animals’ brains causing degenerative changes leading to neurologic signs such as tremors, incoordination or seizures. The disease is not infectious and does not transmit from a live animal to another animal. However, transmission can occur through ingestion of parts of affected animal that contain the prion, such as the brain or spinal cord tissue. This is why BSE has traditionally been associated with a practice consisting of feeding beef-based diets to cows, in order to promote protein intake. This practice is, however, illegal now in most countries, including the US and that has led to a decrease in BSE worldwide.

BSE causes degenerative changes in the patient’s brain, characterized by vacuole formation (http://www.sciencedaily.com)

Transmissible spongiform encephalopathies can nevertheless appear spontaneously in some animals, although very rarely, and it appears that this is what happened in this case. Similar diseases exist in other animal species such as Scrapie in sheep or Chronic Wasting Disease (CWD) in wild deer. Whether or not these diseases can be transmitted to humans remain unclear.

People eating beef containing nervous tissues (brains, spinal cord) of a cow with BSE can a disease called variant Creutzfeldt-Jakob Disease (vCJD) and is closely related to the human-only disease Creutzfeldt-Jakob Disease (CJD). Symptoms of vCJD are very similar to those of BSE in cows and can include tremors, confusion, dementia or difficulty walking. There is unfortunately no treatment or cure for the disease and one of the challenges (in both animals and people) is that the incubation period (amount of time until symptoms appear after exposure) can be very long and it can take decades for the disease to manifest itself.

This case was very promptly detected by the USDA during routine testing and shows the importance of continued disease monitoring like BSE. Although very rare however, they can cause significant public health problems and also critically injure a country’s agriculture. Sometimes, the public opinion is to cut resources for disease monitoring programs that have not detected any disease for some time. However, the fact that such programs do not observe any positive does not reflect failure or lack of usefulness. On the contrary, if we stop looking for these diseases we might miss the next epidemic.

Michael Alpers presenting the movie “Kuru – Science and Sorcery” at the One Health Congress in Melbourne, Australia about his pioneer work leading to the discovery of prion diseases

More information:

CDC – Bovine spongiform encephalopathy

FDA – All about BSE

OIE – Number of BSE cases reported worldwide