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UPDATESINCANINEINFLUENZAVIRUS:MANAGEMENT,DIAGNOSIS,
TREATMENT,PREVENTIONANDVACCINATION
Dr.JasonStull,VMD,MPVM,PhD,DiplomateACVPMDr.JeniferChatfield,DVM,DiplomateACZM
Dr.JarodHansonDVM,DACVPMDr.JustineLee,DVM,DACVECC,DABT
Dr.GarretPachtinger,DACVECC
THANKYOU!
GarretPachtinger,VMD,DACVECC
COO,VETgirl
Introduction
JustineA.Lee,DVM,
DACVECC,DABTCEO,VETgirl
Introduction
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Dr.JeniferChatfield,DVM,DiplomateACZM
Dr.JasonStull,VMD,MPVM,PhD,DiplomateACVPM)
Dr.JarodHansonDVM,DACVPM UnderstandingCanine
InfluenzaandDiagnosticsJarodHanson,DVM,PhD,DACVPM
CanineInfluenza:InfluenzaAinCompanionAnimalSpecies
• Canineinfluenzavirus• Family:Orthomyxoviridae• Negativesense,single-strandedRNAvirus
• Diameter:80-120nm(0.08-0.12um)
• Speciesaffected:dogs,cats,ferrets,guineapigs
• Theinfluenzatriad:humans/birds/swine
• Themammalian/avianmixingpot
CurrentCanineInfluenzaSubtypes
• Hemagglutinin:H• 1-18• 17/18seenonlyinbats
• Neuraminidase:N• 1-11• 10/11seenonlyinbats
H3N8andH3N2aretheprimarysubtypesaffectingdogs• Otherstrains:H1N1,H3N1,H3N2(cats),H5N1,H5N2,H5N6,H6N1,H7N2(cats),H9N2,likelyH7N9
• huH1N1indogs/catsduringthe2009huH1N1humanpandemic
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InfluenzainDogsandCats:2005-Present
• 438totalisolates• 423fromdogs• 15fromcats
Lackofsurveillance:• Influenzasurveillanceincompanionanimalsisabysmalcomparedtohumans,pigs,orpoultry
Howdidwegofromnofluindogstothis?
• ViralMutations• Shift
• MajorchangesinHorNtypes:leadstonewviralphenotypeunrecognizedbytheimmunesystem
• CurrentcanineH3N2viruscontainsaviansegments• Requires2virusestoinfectthesamepatient
• Drift• ViralRNApolymeraselacksaproofreadingmechanism
• Higherrorrateleadsto“new”virusesduringeveryinfection
• Sufficientdriftleadsto:• Renewedsusceptibility• Crossovertonewspecies
• Globalpopulationmovements
InfluenzaStrains:aHistoricalSelection
LPAIH7N2:catsandaveterinarianinNY
CurrentH3N2caninestrains
Otheruniqueflustrainsincompanionspecies
CanineH3N8:it’sstillcirculating
2historicH3N8equinesubtypes
ACloserLookatH3N2EvolutioninDogs/Cats
OriginsinKoreaandChina2005-2007
8yearsofviralevolutionandadaptation
2015outbreakstrainfromKorea
OtherH3N2,includinghumanseasonalstrains
SeparatelineagedevelopinginChina
DivergenceOccurredQuicklyintheUS
SoutheastUS
CentralUS
InitialKoreanstrain
H3N2OriginandEndemicity
• HowdidaKoreanvirusgettotheUS?• Importedshelterdogs• Importedpets
• EpidemicorEndemic?• RepeatedreintroductionsofthevirusfromAsia• Environmental:virusdessicates anddiesoutsidehost• Animalreservoir:feraldogs/cats• Endemic:circulatinginthecanine+/- felinepopulation
• Dogshows• Shelters• Doggiedaycares• Groomingfacilities
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ParadoxicalReverseSeasonalPattern
• Humanseasonalflu:fallintolatespring• Prolongedvirussurvivaltime(cold/lesssunlight)• Peoplespendmoretimeindoorsincloseproximity
• Canine:springintofall• Moretimespentincaninesocialsettings:dogparks• Moretravelwithpets:moreopportunitytotransportvirus• Summer:boardingseason• March-July:>80%ofH3N2canineflureports(datafromProMED-mail)in2016and2017
Thevirusisspreadingwhenenvironmentalconditionsareleastfavorable…
CanineInfluenzaTransmission• Secretions
• DirectContact• Liquids/Droplets(>5umdiameter)
• Essentiallydirectcontact(5feet)• Eyes,upperrespiratorytract
• Aerosols(<5umdiameter,butgreaterviruscontent)• 20feetinanairspace• Lowerrespiratorytract
• MechanicalVentilation• Candisseminatevirusoverlongdistances• HEPAorotherhighefficiencyfilters• HouseholdfilterswithMPR>1900:0.3um-1umparticles
• Fomites• Contaminatedsurfaces,gloves,stethoscopes,laryngoscopes,etc.
CanineInfluenzaDiagnostics
• Acutephase• Serology:the“PRE”sample
• Requires“POST”sampleseveralweekslater• Easyandpartofroutineworkup• Maynotbeusefulifvirusdoesn’tmatchserologyantibodies• Initialsampleshouldhaveno/fewantibodiesinacutepresentation
• Nasal,Oropharyngeal,and/orConjunctivalSwabs• Nasalswabsare2-3timesmorelikelytofindapositivethanOPswabs
• Conjunctivalswabsarehighlydependentontheviruspresent• Tissuesamples:freshlungtissueorswabs
• Chronicphase• Serology:the“POST”sample
AppropriateSwabs
• Polyester/Dacron• Flockswabs• Bacterialcultureswabs• Plastichandles
• Avoid:• Woodenhandles• Cottonswabs(limitedtonovirusrecovery)
FollowtheDiagnosticLab’sRecommendations,butBewareoftheConsequences…
Dessication killsthevirus!!!
DiagnosticLabsandTesting
• Wheretosend:multiplecommercialandacademiclabswithmanytestoptions
• Whattoorder:• Ataminimum:
• H3N8andH3N2PCR• SomelabswillrunamatrixPCRfirst(screeningtest)thensubtypethepositives• Labsrequestingdryswabsaretypicallynotdoingvirusisolation
• Ideally:• Arespiratorypanel:suspectedfluisoftensomethingelse• MatrixPCR,ormultiplexPCRforH3N8,H3N2,H7N2,H1N1+/- H5N1• VirusisolationonanymatrixPCRpositives(mostimportantonPCR-untypable strains)
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EnhancingVirusRecoveryandSurvival
• Don’tusecottonswabs• Don’tpre-moistentheswabs• Don’tfreezethesample,evenoveralongweekend• Moistentheswabwithsalineorviraltransportmedia
• Virusonproperlymoistenedandrefrigeratedswabscansurviveformorethanaweek
• Ensuretubesdonotleakordessicate duringshipment(parafilmortapethecaptothetube)
• Shipsamplesovernightonicepacks
Bestpracticesforsanitationandisolationandlessonslearnedfromprevious
outbreaksJeniferChatfield,DVM,DACZM
Whatweknow…CIVoutbreakstypicallyresultfrom:
• Directdog-to-dogcontact• Fomiteandaerosoltransmissioninstressfulenvironmentswithhighpopulationdensitiessuchas:
• Boarding• Daycare• Grooming• Veterinarymedicalfacilities• Animalshelters• Petstores• Caninesportsorothercompetitions
Isolation?Quarantine?
• Isolation =usedtoseparate ill animalswhohaveacommunicablediseasefromhealthyanimals
• Quarantine =usedtoseparateandrestrictthemovementofwell animalswhomayhavebeenexposedtoacommunicablediseasetoseeiftheybecomeill.Theseanimalsmayhavebeenexposedtoadisease,ortheymayhavethediseasebutdonotshowsigns
Goalofboth=stopdiseasetransmission!
IsisolationofCIVpatientsREALLY necessary?
• Existingpopulationislargelyimmunologicallynaive
• Morbidityrateassociatedwithcanineinfluenzaisestimatedat80%
• CIVH3N2ismuchmorecontagious(orreadilytransmissible)thanH3N8
• IsitCIV?OrCIV+bacterialinfection?OranewCIVstrain?
Howdoweisolate?
• Exteriorentrydirectlyintorarelyusedexamroom,ifpossible
• Separateair-handlingfortreatmentarea/cagearea
• Dedicated/limitedpersonnel• Removewaste(excrement,exudate,etc.)assoonaspossiblefromcage
• NOcontactwithotheranimals
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ProlongedintermittentvirussheddingduringanoutbreakofcanineinfluenzaAH3N2virusinfectionindogsinthreeChicagoareashelters:16cases(MarchtoMay2015)
Sandra Newbury,Jennifer Godhardt-Cooper,KeithP. Poulsen,Francine Cigel, MS; Laura Balanoff, DVM; Kathy Toohey-Kurth;JAVMA.May1,2016,Vol.248,No.9,Pages1022-1026
• EstimateappropriateisolationperiodfordogsinfectedwithCIVH3N2virusonthebasisofthedurationofvirusshedding.
• 16dogs,from3Chicagoareashelters,naturallyinfectedwithCIVH3N2virus.
• VirusesfromeachdogwereidentifiedasCIVH3N2virusonthebasisofDNAsequencing.TheintervalbetweenfirstandlastpositiverRT-PCRassayresultsrangedfrom13to24days
• DogsinfectedwithH3N2virusshouldbeisolatedforaperiodof≥21daysfollowingonsetofillness.
• Evenwhenresolutionofclinicalsignsoccurssoonerthan21days,sheddingofH3N2virusmaypersist.
Afterthesheltersextendedtheirisolationprotocolsto21days,newinfectionsdecreasedsubstantially.
Meanwhile,backintheexamroom…
…disinfectionfollowingsuspected CIVcase!
First,removeanyorganicdebris(clean)
• Cannotdisinfectorganicdebris!
• Cleaningremovesgerms,dirt,andotherdebrisfromsurfaces
Disinfecthardsurfaces
• Disinfectingkillsgermsonsurfaces• Useproductsaccordingtolabelinstructions– includingallowingforcontacttime
• Softitems(towels,blankets,etc.)canbewashedasroutine(recommendhotwater,detergent,andbleach)
• Itemsthatcannotbewashedshouldbediscardedappropriately
Disinfectionfollowingsuspected CIVcase
• Quaternaryammoniumcompounds(i.e.benzalkonium chloride)• Aldehydes• Potassiumperoxymonosulfate• Phenols• Bleach(1:30) solutions
Besuretoallowsufficientcontacttime!
WashinghandsisCRITICAL
• Handwashingreducestransmissionofrespiratoryillness• Rabie T,CurtisV.Handwashingandriskofrespiratoryinfections:aquantitativesystematicreview.TropicalMedicineandInternationalHealth2006;11(3):258-267.
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Staff
• Limitedpersonnelincontactwithaffecteddogs• Personnelcontactpatientsinthisorder:
1. Healthy2. Young3. Oldest4. Sickest
• Ifpossible,onlystaffwithnodogsathomehandlepotentialCIVcases
• Considerchangingscrubtops,footbaths,etc.
Educatestaffandclientsonproperinfectioncontrol
DiseasePreventionwithDogsinGroupSettings
JasonStull,VMD,MPVM,PhD,DACVPM
TheCanineGroupSetting
• Cometogether• Sharedenvironment• Temporary• Manydogs• Local/International
• Shows• Sportingevents• Dogparks• Trainingclasses• Dogdaycare• Boarding
Diseaseoutbreaks?Localcommunity,widespread?
MultipleFactorsInfluenceInfectionRisks
Environmental disinfection
Hand hygieneContact precautions
Surveillance Antimicrobial Use
Event/Facility
Infections
AnimalProcedures
Outbreaks &Into
Community
Education & Awareness
Vaccination
RecommendationAreas
1. General:nosickdogs2. Vaccination:core+lifestyle3. InsectandWildlifeControl4. Vectorandvector-bornedisease5. Entericdisease6. Environmentaldisinfection/hygiene7. Facilitydesignandtrafficcontrol8. Diseaserecognition/response:exposeddogs
Keyforcaninefluprevention
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Vaccination
•Coreforgroupsettings• Distemper• Adenovirus• Parvovirus• Rabies• Bordetella• Parainfluenza
•Timeforimmunityandboosters
Non-CoreVaccination
• Basedonrisk• CaninefluH3N8andH3N2
• 2doses,2-4weeksapart• Annualbooster
• Lyme• Leptospirosis
EnvironmentalDisinfection&Hygiene
•Staff&ownersperformhandhygiene• Entryandexittoevent• Betweendogcontacts(groups)
EnvironmentalDisinfection&Hygiene
•Reducemulti-dogcontacttoitems• Bring(anduse)ownitems• Singledoguseprovidedbysetting
FacilityDesignandTrafficControl
•Unnecessarydog-dogandperson-dogcontact
•Duringanoutbreakavoidhighlypopulateddogareas
PetOwnerCommunication
• Asktherightquestions• Helptounderstandandalterrisk• Open,two-wayexchangeofinformationandopinion• Empowertomake informeddecisions
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AvailableResources
http://go.osu.edu/IDk9risk
RiskCalculator• Audience:Public• 5-10min• Immediatepersonalizedfeedbackonriskreduction
http://go.osu.edu/IDk9risk
Checklist
http://go.osu.edu/IDk9risk
Clinicalsignsandtransmission
JustineLee,DVM,DACVECC,DABT
ClinicalsignsofCIV
• Coughing(95%)• Lethargy/weak(70%)• Inappetance(63%)• Fever(58%)• Nasal/oculardischarge(49%)• GIsigns(27%)• Pneumonia(20%)
• Tachypnea(atrest)• Tachycardia• Coupageà cough• Constantpanting• Dyspnea• Exerciseintolerance• Cyanosis• Collapse
Physicalexamination
•Coughing•Lethargic•Nasal/oculardischarge•Dehydration•Fever(T>103°F/39.4°C)•Abnormalauscultation
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CanineInfluenza• Mildform:
• Cough– canbeverypersistent,30-60days• Fever• Nasaldischarge
• Severeform:• Pneumoniawithhypoxiain~10%ofdogs• Mortalityrateupto8%
• Secondarybacterialinfectionsarecommonandworsenclinicalsigns• Nasal:Staphs andStreps• Pulmonary:Bordetella andMycoplasma• Strepzooepidemicus (hemorrhagicpneumonia)
TreatmentJustineLee,DVM,DACVECC,DABT
Primarysurvey
• Immediateassessment
• StabilizationoftheABCDs!• Airway• Breathing• Circulation• Dysfunction
•Cyanotic=paO2 <40mmHg• Abouttoarrest– treatimmediately!
•O2 therapy!
GoalsofTreatment
•Hydration•Oxygenation•Antibiotictherapy•Nebulizationandcoupage• Supportivecare•Anti-emetictherapy
Treatmentprotocols:IVfluidtherapy
• Ensurehydration• Preventdehydrationofairwaysecretionswhichworsenabilitytobeexpectorate
• Replacehydrationoverseveralhours• Crystalloid
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OxygenTherapy
• Oxygen• Pulseox<92%?NEEDSO2!
• EstablishAirway
• IVaccess
Antibiotictherapy
•Viralinfectionbutconcernaboutsecondaryseptichemorrhagicsyndromeinseverecases
•Mixedbacterialflora• Gram+/-
•Combinationbroad-spectrumantibiotictherapy
•Routeofdelivery• IVorIM• Ifstable,switchtooralafterinitialIV/IMdose
Antibiotictherapy• Broadspectrumantibioticsifsecondarybacterialinfectionsuspected• Doxycycline• Amoxicillin/clavulonic acid• Enrofloxacin +amoxicillin/clavulonic acid• Enrofloxacin +cefazolinorampicillin• Amikacininhydratedpatientsonly
Nebulizationandcoupage• Goals:
• Hydrate• Loosen/expectoratesecretions
• Promoteexpectoration
• Coupageq.4-6hours
Miscellaneoustreatment•Coolingmeasures?
• IfveryelevatedTà DIC• StopcoolingatT>103°F/39.4°C
•Analgesics• Ifpainful,treat.• Beawareofrespiratorydepressionandcoughsuppressionw/opioids
•One-time,anti-inflammatorydoseofDexSP?• Viral!
Treatment
• Tamiflu- notrecommended• Antibiotics- secondaryinfections
•ShouldbebasedonC&S• B.bronchiseptica
• Doxycycline,TMS• AlwaysresistanttoCephalexin
• Strep.Zooepidemicusorothersecondarybacterialinfections• Clavamox,cephalosporins,fluoroquinolones
• Onlyusesteroidsandanti-tussivesifabsolutelynecessary• Rest• +/- nebulizersandcoupage
•Mayincludeaerosolizedantibiotics
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Furtherdiagnostics
• Physicalexamination(PE)• Chestradiographs• Pulseoximeter• Arterialbloodgas
Summaryoftreatmentrecommendations
•Coughsuppressants onlyifbacterialpneumoniaisruledout.
• Immediateisolation
• Lowstressenvironment
Furtherdiagnostics
• Oralantibiotictherapyfor2-6weeks
• Recheckserialradiographs
• Continueantibiotics1-2weekspastresolutionofradiographicdisease
Appropriateclientcommunication
• Educateownersappropriately
• Discusspreventativecare• Nodoggydaycares• Minimizedogexposure• Vaccination?
• Recognizeandtreatappropriately
Sohowdoweprotectourcaninepatients?
ToolsforPreventionofCIRDcomplex:Vaccines
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Conclusion
• Rapidrecognition• Appropriatehistory(e.g.,travel,boarding)• Appropriateeducation• Re-evaluateyourboardingpolicy• Appropriatedisinfection• Minimizenose-to-nosecontactduringoutbreaks• Vaccinationwhenappropriate
Q&A
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