A Survey of Maryland Veterinarians Lyme Disease Diagnosis

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A Survey of Maryland Veterinarians: Lyme Disease Diagnosis, Treatment, and Prevention in Canines Caitlin

A Survey of Maryland Veterinarians: Lyme Disease Diagnosis, Treatment, and Prevention in Canines Caitlin Cotter, DVM DHMH PHASE Intern, 2016 Johns Hopkins School of Public Health Katherine Feldman, DVM Center for Zoonotic and Vector-borne Diseases MD Department of Health and Mental Hygiene Photo credit: CT Veterinary Diagnostic Laboratory

Lyme Disease in MD Canines Ø Background Ø Clinical Signs & Diagnostics Ø ACVIM

Lyme Disease in MD Canines Ø Background Ø Clinical Signs & Diagnostics Ø ACVIM Consensus Statement Ø Study: Survey of Maryland Veterinarians Ø Analysis Ø Results Ø Conclusions

Background • Lyme disease • Spirochete bacteria • Borrelia burgdorferi • Ixodes ticks •

Background • Lyme disease • Spirochete bacteria • Borrelia burgdorferi • Ixodes ticks • White-footed mouse • Humans, Canines Photo credit: Warde Medical Laboratory, Cary Institute

Clinical Signs/Symptoms Humans • 70 -80% erythema migrans “bullseye” target rash • Flu-like symptoms

Clinical Signs/Symptoms Humans • 70 -80% erythema migrans “bullseye” target rash • Flu-like symptoms • Arthritis, carditis, neurological disease Photo credits: borreliaburgdorferi. com, Merck Veterinary Manual Dogs • No rash • Polayrthropathy • Fever • Anorexia • Lyme nephropathy

Diagnostics Humans Dogs • Signs & Symptoms • SNAP • Tick exposure history •

Diagnostics Humans Dogs • Signs & Symptoms • SNAP • Tick exposure history • EIA / Western Blot point-of-care ELISAs • Quantitative C 6 antibody assay • Other serology, lymphocyte assays, joint fluid tests not • Urinalysis recommended • Urine protein-creatinine ratio Photo credits: University of Michigan Medical School, www. lymeinfo. ca

ACVIM Consensus Statement • Screening for Lyme disease in canines • Benefits: early detection

ACVIM Consensus Statement • Screening for Lyme disease in canines • Benefits: early detection of Lyme nephropathy, seroprevalence tracking • Risks: overdiagnosis, overtreatment; poor prediction of clinical disease; antimicrobial resistance (AMR) • Treatment of asymptomatic positive dogs • Unknown: is treatment of seropositive, health dogs beneficial? • Case-by-case decisions: consider dog breed (shelties, retrievers), AMR • Vaccination • Not recommended for seropositive dogs • Seropositivity indicates tick exposure. • Check for tick-borne co-infections, evaluation for proteinuria • Tick control

Survey of Maryland Veterinarians • Screening • How often do you screen dogs for

Survey of Maryland Veterinarians • Screening • How often do you screen dogs for Lyme disease? • Why do you *Screen annually? *Not recommend annual screening? • Treatment • How do you manage asymptomatic, Lyme SNAP-test positive dogs? • Vaccination • Is Lyme vaccination mandatory, based on risk, or not performed? • Follow-Up Testing • Which follow-up tests do you recommend? • Is follow-up urinalysis repeated annually?

Analysis • Descriptive analysis • Veterinary practice characteristics and location in MD • Veterinarian

Analysis • Descriptive analysis • Veterinary practice characteristics and location in MD • Veterinarian preferences • Diagnosis and prevention of Lyme disease • Veterinarian beliefs • Treating SNAP- test positive dogs • Perception of Lyme disease risk • Associations between survey variables

Practice Location Anne Arundel Maryland county Montgomery (n=191) Baltimore City Other counties No. 29

Practice Location Anne Arundel Maryland county Montgomery (n=191) Baltimore City Other counties No. 29 29 18 115 % 15. 8% 9. 8% 58. 6%

Practice Characteristics Number of vets in practice (n=180) Practice type (n=183) No. % 1

Practice Characteristics Number of vets in practice (n=180) Practice type (n=183) No. % 1 to 3 76 3. 8% 4 or more 104 57. 8% 165 90. 2% 11 6. 0% Exclusively small animal Mixed animal Photo Credits: Woodlake Animal Hospital, Redmond Vet Clinic

Veterinarian Perception of Canine LD Risk High Risk Perception of risk for canine Moderate

Veterinarian Perception of Canine LD Risk High Risk Perception of risk for canine Moderate Risk Low Risk LD (n=191) Not At Risk Other No. 114 71 2 0 4 % 59. 7% 37. 2% 1. 0% 0. 0% 2. 1%

Use of LD Screening Tests Idexx SNAP 4 Dx Screening with which Lyme Idexx

Use of LD Screening Tests Idexx SNAP 4 Dx Screening with which Lyme Idexx SNAP 3 Dx disease test Antech Accuplex panel (n=148) PCR Other Photo credits: Idexx, Antech No. 117 % 79. 1% 12 8. 1% 17 11. 5% 0 2 0% 1. 4%

Frequency of LD Screening (n=145) Annually Only with clinical signs No screening recommended Other

Frequency of LD Screening (n=145) Annually Only with clinical signs No screening recommended Other No. 145 23 3 19 % 76. 3% 12. 1% 1. 6% 10. 0%

Reasons for Annual Screening % Reason for annual LD screening (n=155) Endemicity of disease

Reasons for Annual Screening % Reason for annual LD screening (n=155) Endemicity of disease No. 127 Tracking seroprevalence 46 29. 7% Informing dog owners 72 46. 5% (multiple answer selections possible) Annual heartworm testing, with LD test included Other 60 38. 7% 4 2. 6% Photo credit: CDC 81. 9%

Reasons for Not Recommending Annual Screening No. Reason to not recommend Test does not

Reasons for Not Recommending Annual Screening No. Reason to not recommend Test does not annual LD screening diagnose or predict (n=35) disease Overdiagnosis/ overtreatment (multiple selections Expense of treatment possible) Antimocrobial resistance Unnecessary owner distress Other Photo credit: www. iran-daily. com 17 % 48. 6% 14 40. 0% 3 8. 6% 6 17. 1% 10 28. 6%

Follow-Up Diagnostic Testing If perform follow-up tests, which Quantitative Lyme C 6 tests recommended

Follow-Up Diagnostic Testing If perform follow-up tests, which Quantitative Lyme C 6 tests recommended (n=59) Urinalysis (multiple answer selections possible) Urine Protein: Creatinine Ratio Serum Chemistry/CBC Other Is urinalysis follow-up repeated Yes No annually? (n=60) We do not perform UA for dogs screening positive No. % 42 71. 2% 38 64. 4% 17 28. 8% 20 33. 9% 4 6. 8% 32 53. 3% 18 30. 0% 10 16. 7%

Management of Asymptomatic, SNAP-test Positive Dogs Treatment of asymptomatic dog screening positive (n=149) No.

Management of Asymptomatic, SNAP-test Positive Dogs Treatment of asymptomatic dog screening positive (n=149) No. % Treat all positive dogs with antibiotics Treat the first time screening positive, then based on clinical signs Perform follow-up testing 11 7. 4% 55 36. 9% 59 39. 6% No treatment or follow-up without clinical signs Other 9 6. 0% 15 10. 1%

Lyme Vaccination Do you use a Lyme vaccine (n=187) Lyme vaccine brand used (n=182)

Lyme Vaccination Do you use a Lyme vaccine (n=187) Lyme vaccine brand used (n=182) (multiple selections possible) Mandatory, core vaccine Vaccinate if high risk No Lyme vaccination Other Lyme. Vax, Zoetis Recombitek Lyme, Merial Duramune Lyme combo, BI Other % No. 60 88 4 35 32. 1% 47. 1% 2. 1% 18. 7% 39 87 43 21. 4% 47. 8% 23. 6% 25 13. 7%

Associations Treating asymptomatic positive dogs with antibiotics Annual Screening Photo credit: www. crossingthinice. com

Associations Treating asymptomatic positive dogs with antibiotics Annual Screening Photo credit: www. crossingthinice. com Yes No Chi-squared p-value Yes 68 78 0. 067 No 3 0

Conclusions • ACVIM recommends weighing benefits and risks of Lyme disease screening • 76.

Conclusions • ACVIM recommends weighing benefits and risks of Lyme disease screening • 76. 3% of veterinarians screen annually • ACVIM recommends case-by-case decisions: treatment of asymptomatic positive dogs • 7. 4% veterinarians treat all asymptomatic positives • 36. 9% of veterinarians treat all dogs at first seropositivity • ACVIM does not recommend vaccinating seropositive dogs • Majority (79. 2%) of Maryland veterinarians recommend Lyme as core vaccine or recommend if patient at high risk • 96. 9% feel patients are at high risk • How many are seropositive at time of vaccination?

ACVIM does recommend • For asymptomatic dogs screening positive: • Check for tick-borne co-infections,

ACVIM does recommend • For asymptomatic dogs screening positive: • Check for tick-borne co-infections, • Evaluate for proteinuria • Tick control Photo credit: Loomis Urinalysis Testing

Next Steps • More research is necessary • Is treatment of asymptomatic positive dogs

Next Steps • More research is necessary • Is treatment of asymptomatic positive dogs beneficial? • Are SNAP diagnostic tests beneficial? • Updated Consensus Statement • ACVIM • Screening, treatment: seropositive canines • Detailed algorithm • Currently known risks and benefits of treatment • Various screening and disease stages

Thank You! • DHMH State Public Health Veterinarian: • Dr. Katherine Feldman CZVBD /

Thank You! • DHMH State Public Health Veterinarian: • Dr. Katherine Feldman CZVBD / DHMH Team: Kim Mitchell S. B. Wee Heather Rutz Mary Armolt Richard Brooks Michael King Andrea Palmer David Blythe Lucy Wilson Shaylee Mehta