BEYOND KENNEL COUGH.. what are the concerns and calls for ac=on? Cynda Crawford, DVM, PhD Maddie s Shelter Medicine Program University of Florida OVERVIEW What is kennel cough? What pathogens cause kennel cough? Are there pathogen- specific concerns? What is the call to ac6on? What is the ac6on? October 10-13, 2013 1
Is this kennel cough? 3 WHAT IS KENNEL COUGH? 4 October 10-13, 2013 2
WHAT IS KENNEL COUGH? 5 WHAT IS KENNEL COUGH? 6 October 10-13, 2013 3
Beyond Kennel Cough: Diagnosis and Management of Respiratory WHAT IS KENNEL COUGH? 7 Clinical syndrome of sneezing, coughing, and nasal/ocular discharge WHAT IS KENNEL COUGH? 8 Canine infec6ous respiratory disease (CIRD) is the preferred term October 10-13, 2013 4
CIRD = MULTI- PATHOGEN 9 VIRUSES BACTERIA Parainfluenza virus (CPiV) Adenovirus type 2 (CAV) Distemper virus (CDV) Influenza virus (CIV) Respiratory coronavirus (CRCoV) Pneumovirus (CnPnV) Herpes virus (CHV) Bordetella bronchisep6ca Mycoplasma cyanos Streptococcus zooepidemicus COMMON PATHOGEN PROPERTIES Highly contagious and easily transmined in kennel seongs Propensity to colonize both the upper and lower respiratory tract Frequently have mixed viral and bacterial co- infec6ons 10 October 10-13, 2013 5
COMMON PATHOGEN PROPERTIES 11 All cause clinical and subclinical infec6ons All cause the same clinical picture Cough Sneezing Nasal/ocular discharge ± Pneumonia COMMON TRANSMISSION MODES 12 Direct contact Aerosols generated by sneezing and coughing Travel 20 feet Major mode of spread within a room Fomites (incl. people) October 10-13, 2013 6
BEYOND KENNEL COUGH DIFFERENT CONCERNS FOR DIFFERENT CAUSES? 13 TRADITIONAL Bordetella bronchisep6ca CPiV CAV2 CDV CRCoV CIV CnPnV EMERGING Strep zooepidemicus Mycoplasma cyanos TRADITIONAL CIRD PATHOGENS October 10-13, 2013 7
BORDETELLA S6ll a frequent pathogen for shelter dogs Transient disease in adults (5-7 days) Can cause severe pneumonia in puppies BORDETELLA Establishes chronic infec6on in untreated dogs IntermiNent relapses and shedding for months Suscep6ble to doxycyline, minocycline, Clavamox Resistant to TMS and cephalosporins October 10-13, 2013 8
CPIV AND CAV2 Frequent co- pathogens with other respiratory viruses and bacteria Mild/transient disease (5-7 days) Large number of subclinical infec6ons Contagious but likely shed less virus than sick dogs CDV 17 Frequent cause of depopula6on in shelters >50% of dogs entering Florida shelters have no protec6ve immunity (Lechner. JAVMA 2010; 236:1317) October 10-13, 2013 9
Systemic infec6on! Respiratory tract GI tract Ocular tract Urinary tract Skin CNS CDV CDV Infec6on of mul6ple systems confounds recogni6on and causes frequent misdiagnosis Virus shed from respiratory tract and in feces/urine October 10-13, 2013 10
EMERGING CIRD PATHOGENS CRCoV Most dogs are suscep6ble Endemic in many shelters Frequent co- pathogen Milder/transient disease Large number of subclinical infec6ons Not related to the canine enteric coronavirus October 10-13, 2013 11
CIV 21 Most dogs are suscep6ble Explosive number of coughing dogs in a short period of 6me epidemics in shelters Small number of subclinical infec6ons Can cause high fever/severe pneumonia requiring hospital care CIV Dogs in shelters are highest risk group (Anderson. JAVMA 2013;242:209) Endemic in shelters in the Northeast and CO Has caused depopula6on in shelters in several states October 10-13, 2013 12
CnPnV Canine pneumovirus ini6ally iden6fied in dogs with CIRD in NYC shelters in 2010 (Renshaw. Emerg Infect Dis 2010;16:993) Most dogs are suscep6ble Explosive number of coughing dogs over short 6me epidemics Can cause high fever/severe pneumonia like CIV STREP ZOO Lancefield group C beta- hemoly6c strep bateria Two clinical syndromes Sudden death due to fulminant hemorrhagic pneumonia Cough/nasal discharge that rapidly progresses within hours to respiratory distress, hemorrhage from nose, and death October 10-13, 2013 13
Beyond Kennel Cough: Diagnosis and Management of Respiratory STREP ZOO Sudden death syndrome Hemorrhage from nose and mouth Death due to hemorrhagic pneumonia and hemothorax STREP ZOO An6bio6c therapy for infected dogs Sensi6ve to penicillin, Clavamox, cephalexin, Convenia Some strains resistant to doxycycline and fluoroquinolones October 10-13, 2013 14
MYCOPLASMA CYANOS Frequent co- infec6on in dogs with respiratory infec6ons ini6ated by other pathogens Lung damage may promote infec6on Role as a primary pathogen unclear Sensi6ve to doxycyline, minocycline, azithromycin, ± fluoroquinolones COMMON RESPONSE TO KENNEL COUGH Treat affected dogs with doxycycline for 7 days May or may not be moved to an isola6on ward Most of the 6me this approach works Doxycycline is appropriate for true Bordetella infec6ons Tradi6onal respiratory viruses (CPiV, CAV2) cause mild transient infec6ons that resolve in a week What to do if this approach is not working? October 10-13, 2013 15
BEYOND KENNEL COUGH WHAT IS THE CALL TO ACTION? Triggers for inves6ng in diagnos6c tes6ng Increased number of sick dogs Increased severity of disease, including pneumonia and death Increased dura6on of disease Complaints from adopters and community veterinarians BEYOND KENNEL COUGH IS THIS A CALL TO ACTION? October 10-13, 2013 16
BEYOND KENNEL COUGH IS THIS A CALL TO ACTION? BEYOND KENNEL COUGH IS THIS A CALL TO ACTION? 34 October 10-13, 2013 17
BEYOND KENNEL COUGH RULES AND TOOLS FOR LIFE- SAVING INTERVENTION Diagnos6c tes6ng Isola6on of sick animals Quaran6ne of exposed animals Create a clean break to prevent exposure of new animals Strict biosecurity protocols Environmental decontamina6on WHY PERFORM DIAGNOSTIC TESTING? Proper pa6ent management Treatment op6ons and cost Prognosis for recovery Average 6me to recovery October 10-13, 2013 18
WHY PERFORM DIAGNOSTIC TESTING? Essen6al for successful interven6on strategies Risk for spread to other dogs Isola6on 6me for sick dogs Quaran6ne 6me for exposed asymptoma6c dogs No or late diagnosis increases number of infected dogs WHAT TEST? Cannot diagnose by clinical signs! Best diagnos6c approach is tes6ng of swabs from the upper respiratory tract using PCR PCR detects the pathogen DNA Very sensi6ve and specific Rapid turnaround 6me for results (2-3 days) 6mely pa6ent and popula6on management Moderate cost: $82- $115/sample dependent on diagnos6c lab October 10-13, 2013 19
CIRD PCR PANELS Canine Respiratory Disease RealPCR Panel (Idexx) CPiV CAV2 CDV (quan=ta=ve) CIV CRCoV CHV Bordetella bronchisep:ca Mycoplasma cyanos Streptococcus zooepidemicus Fast Panel PCR Canine Respiratory Disease Profile (Antech) CPiV CAV2 CDV CIV CRCoV CHV Bordetella bronchisep:ca Mycoplasma cyanos Streptococcus zooepidemicus CIRD PCR PANELS Canine Respiratory PCR Panel (Cornell Animal Health Diagnos=c Center) CPiV CAV2 CDV CIV CRCoV CnPnV Bordetella bronchisep:ca Mycoplasma cyanos Canine Respiratory PCR Panel (Zoologix) CAV2 CDV CIV CHV Bordetella bronchisep:ca October 10-13, 2013 20
CIRD PCR PANELS Canine Respiratory PCR Panel (Abaxis) CPiV CAV2 CDV CIV CRCoV CHV Bordetella bronchisep:ca HOW TO TEST? Supplies: swabs, plain red top tubes, exam gloves Individually wrapped dacron swabs Bacterial culturenes Acceptable October 10-13, 2013 21
HOW TO TEST? Wear exam gloves PCR is subject to false posi6ves from DNA contamina6on of hands aser touching surfaces and dogs Change gloves between dogs HOW TO TEST? Collect at least 2 swabs from different sites for each dog Conjunc6val Nasal Deep pharyngeal October 10-13, 2013 22
Nasal swabs Conjunctival swabs Pharyngeal swabs HOW TO TEST? Insert swab 6p into red top tube and release by snapping the swab handle Combine all swab 6ps in one tube October 10-13, 2013 23
TIMING OF SAMPLE COLLECTION? Dependent upon incuba6on and shedding periods for each pathogen Incuba=on period Shedding period CPiV/CAV CDV CIV CRCoV CnPnV <1 week ~2 weeks <1 week <1 week <1 week? 1 week weeks to months 1 week 1 week? 1 week? Bordetella Strep zoo Mycoplasma Incuba=on period < 3 days < 3 days? days Shedding period (w/o an=bio=cs) months? weeks? WHO TO TEST? Acute cases Most viruses only detectable during first few days of illness Exposed cases Peak pathogen shedding during incuba6on period Test at least 10 of the acutely ill/exposed cases Increases accuracy and determines a panern October 10-13, 2013 24
TESTING WINDOWS 10 9 Virus shedding Clinical disease Amount virus/clinical disease 8 7 6 5 4 3 2 1 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Days aler infec=on DIAGNOSTIC DILEMMA? PCR detec6on of live vaccine strains in recently vaccinated dogs Can t differen6ate between vaccine or pathogenic strains Modified- live Bordetella, CPiV, and CAV2 in intranasal vaccine are shed for weeks (Iemura. Vet Record 2009;165:747) Difficult to interpret posi6ve PCR test results for these pathogens in vaccinated dogs October 10-13, 2013 25
DIAGNOSTIC DILEMMA? PCR detec6on of modified- live CDV, CPiV, and CAV2 in DAPP given SQ Detec6on in <20% healthy dogs during 1 st 2 weeks postvax (Leutenegger, Crawford, Levy. 2011 ACVIM Forum abstract) Will not detect recombinant CDV in the Merial canarypox DAPP vaccine Idexx created a quan6ta6ve CDV PCR test to differen6ate between vaccine and wild type strains based on viral counts IDEXX QUANTITATIVE CDV PCR Differen6ate vaccine strains from wild type strains based on quan6ty of virus on swabs Validated by studies on samples collected from vaccinated healthy dogs and truly infected dogs 3 ranges for CDV virus par6cles/sample <105,000: vaccine strain 105,000-1,000,000: indeterminate >1,000,000: wild type infec6on October 10-13, 2013 26
IDEXX QUANTITATIVE CDV PCR TEST RESULT CANINE DISTEMPER VIRUS POSITIVE CDV QUANTITY 2 thous/swab [<105,000] CDV INTERPRETATION CDV VACCINE INTERFERENCE: If the dog has been vaccinated with modified- live CDV strain within past few weeks, the posi6ve result may be due to detec6on of the vaccine strain. If the dog has not been vaccinated recently or received the recombinant CDV vaccine, the posi6ve result is consistent with the early or recovery phases of wild type infec6on, par6cularly if there is known exposure or compa6ble clinical signs. Re- tes6ng in 1-2 weeks is recommended. VIRUS SHEDDING IN CDV- INFECTED DOGS 1.00E+09 - - Crawford and Levy. 2011 ACVIM Forum abstract 1.00E+08 1.00E+07 Vaccine strain threshold Indeterminate 1.00E+06 CDV 1.00E+05 1.00E+04 1.00E+03 1.00E+02 1.00E+01 1.00E+00 0 14 28 42 56 70 84 96 Days pos=nfec=on October 10-13, 2013 27
Beyond Kennel Cough: Diagnosis and Management of Respiratory CASE 1 Open admission municipal shelter Annual intake = 6000 dogs and cats Intake vaccines: modified- live DAPP/no Bordetella vaccine Kennel A: 45 dogs in stray hold Kennel B: 30 dogs for adop6on Kennel C: 18 legal custody dogs 10/1/13: 20% of dogs in Kennels A/B have kennel cough CASE 1 ADOPTION October 10-13, 2013 28
CASE 1 - ADOPTION Idexx CIRD PCR panel TEST CDV Bordetella CAV2 CHV CPiV CIV CRCoV Mycoplasma cyanos Strep zooepidemicus RESULT Posi6ve Posi6ve CASE 2 Open admission municipal shelter Annual intake = 25,000 dogs and cats Intake vaccines: modified- live DAPP/modified- live Bordetella/CPiV/CAV2 Stray Hold/Legal Custody Building: 200 double- sided runs Adop6on Building: 100 double- sided runs Isola6on Ward: separate sec6on in Stray Hold Building October 10-13, 2013 29
CASE 2 CASE 2 ADOPTION BUILDING October 10-13, 2013 30
CASE 2 ADOPTION BUILDING Idexx CIRD PCR panel TEST CDV Bordetella CAV2 CHV CPiV CIV CRCoV Mycoplasma cyanos Strep zooepidemicus RESULT Posi6ve Posi6ve Posi6ve Posi6ve Posi6ve CASE 2 STRAY BUILDING October 10-13, 2013 31
CASE 2 STRAY BUILDING Idexx CIRD PCR panel TEST CDV Bordetella CAV2 CHV CPiV CIV CRCoV Mycoplasma cyanos Strep zooepidemicus RESULT Posi6ve Posi6ve Posi6ve Posi6ve CASE 3 Limited admission humane society Annual intake = 1600 dogs and cats Intake vaccines: modified- live DAPP/modified- live Bordetella/CPiV/CAV2 Dogs housed in individual runs and in group rooms Progressive increase in number of pups and adults with kennel cough; 2 pups died Seemed to correspond with admission of dogs from local county shelter October 10-13, 2013 32
CASE 3 - PUPPY Puppy with rapidly progressive disease. Day 7 aser DAPP vax on intake. CASE 3 SICK PUPPY Idexx CIRD PCR panel TEST RESULT QUANT CDV Posi6ve - 5000 Bordetella CAV2 CHV CPiV CIV CRCoV Mycoplasma cyanos Strep zooepidemicus Posi6ve Posi6ve October 10-13, 2013 33
CASE 3 - ADULT Young adult with copious nasal discharge 14 days aser DAPP vax. Recovered aser 7 days on doxy. Idexx CIRD PCR panel TEST CASE 3 ADULT RESULT QUANT CDV Posi6ve 153,000 Bordetella CAV2 CHV CPiV CIV CRCoV Mycoplasma cyanos Strep zooepidemicus Posi6ve October 10-13, 2013 34
CASE 4 Open admission municipal shelter Annual intake = 12,000 dogs and cats Intake vaccines: modified- live DAPP/modified- live Bordetella/CPiV/CAV2 Stray Hold/Custody Ward Adop6on Ward No isola6on ward CASE 4 Open admission municipal shelter Progressive increase in number of dogs with kennel cough for past 6 months in all housing areas More severe and longer dura6on of illness than normal Idexx CIRD PCR panels: Bordetella and mycoplasma Not really responsive to doxy October 10-13, 2013 35
CASE 4 CASE 4 Cornell CIRD PCR panel TEST CDV Bordetella CAV2 CPiV CIV CRCoV CnPnV Mycoplasma cyanos RESULT Posi6ve Posi6ve Posi6ve October 10-13, 2013 36
BEYOND KENNEL COUGH RULES AND TOOLS FOR LIFE- SAVING INTERVENTION Diagnos6c tes6ng Isola6on of sick animals Quaran6ne of exposed animals Create a clean break to prevent exposure of new animals Strict biosecurity protocols Environmental decontamina6on ISOLATION OF SICK DOGS Single most important step Physical containment of pathogen Reduces infec6ous dose in the general popula6on Reduces transmission to more dogs Separate staff and supplies Full PPE (gowns, tyvek suits, boots, gloves) October 10-13, 2013 37
ISOLATION OF SICK DOGS What if there is no isola6on ward? ISOLATION OF SICK DOGS Alterna6ves to isola6on in the shelter Medical foster homes Transfer to another agency with good facili6es Rent a warehouse Disaster response trailers October 10-13, 2013 38
ISOLATION OF SICK DOGS Isola6on 6me = pathogen shedding period Shedding period CPiV/CAV CDV CIV CRCoV CnPnV 1 week weeks to months 1 week 1 week? 1 week? Is the infec6on treatable in the shelter? Dura6on of shedding period Severity of disease Sufficient medical support for the pa6ent QUARANTINE OF EXPOSED DOGS No clinical disease why? Infected but in preclinical incuba6on period Subclinical infec6on Not infected Quaran6ne = no dogs in/no dogs out un6l infec6ous status determined House separately from other dogs Separate staff and supplies (PPE) October 10-13, 2013 39
QUARANTINE OF EXPOSED DOGS Quaran6ne 6me = pathogen incuba=on period Incuba=on period CPiV/CAV CDV CIV CRCoV CnPnV <1 week ~2 weeks <1 week <1 week <1 week? Monitor for clinical signs daily Promptly remove sick dogs to isola6on Restart quaran=ne clock CREATE A CLEAN BREAK No exposure of other dogs to isolated or quaran6ned dogs Best op6on: no admission of new dogs BeNer op6on: separate building for new admissions Good op6on: separate ward for new admissions Marginal op6on: one end of the quaran6ne ward October 10-13, 2013 40
CREATE A CLEAN BREAK Limited admission non- profit shelters Stop all admissions/adop6ons Open admission municipal shelters Stop intake of owner surrenders Restrict intake to minimum legal requirement (injured strays, bite quaran6ne, dangerous dogs) Use temporary housing for must- admits (tents, warehouses) Stop adop6ons from the shelter Adopt fosters directly from foster homes or at off- site events BEYOND KENNEL COUGH. Can clinical presenta6on Stop all admissions/adop6ons Open admission municipal shelters Stop intake of owner surrenders Restrict intake to minimum legal requirement (injured strays, bite quaran6ne, dangerous dogs) Use temporary housing for must- admits (tents, warehouses) Stop adop6ons from the shelter Adopt fosters directly from foster homes or at off- site events October 10-13, 2013 41
SUMMARY Kennel cough is a clinical syndrome typically caused by co- infec6ons with different viral and bacterial pathogens Some pathogens cause disease panerns that are beyond simple kennel cough Calls to ac6on are prompted by unusual disease panerns and treatment failures There are rules and tools for life- saving interven6on strategies MADDIE S SHELTER MEDICINE PROGRAM Our Mission: To enhance the health and welfare of homeless animals through educa:on, innova:on, and advancement of the life- saving goals of sheltering programs Our Vision: A comfortable and enriched life for all companion animals October 10-13, 2013 42