中國疾病預防控制中心ZOHU呼叫2020年2月5日 (CDC ZOHU Call February 5, 2020)

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>> Welcome and thank you for standing by.
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Now, I would like to turn the call over to your host
for today, Ms. Ria Ghai.
Ms. Ghai, you may begin.
>> Thanks so much, Brad.
Good afternoon everyone.
My name's Ria Ghai, and I work at the One Health office
of the National Center of Emerging
and Zoonotic Infectious Diseases at the Center
for Disease Control and Prevention.
On behalf of the One Health office,
I'm pleased to welcome you to the monthly Zoonoses
and One Health Update call for today, February 5th, 2020.
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Before we begin today's presentation, Colin Basler,
a veterinarian epidemiologist with CDC's National Center
for Emerging and Zoonotic Infectious Diseases will share
some news and updates.
Colin, please go ahead.
>> Thanks, Ria.
Hi everyone.
Thanks for joining us for today's ZOHU call,
and welcome to our new participants.
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To begin today's call, I'd like to share some highlights
from the One Health News from CDC included
in today's ZOHU call email newsletter.
CDC's latest antibiotic resistance investments map is
now available.
And the United Nations has declared 2020 the international
year of plant health.
Some upcoming conferences include two here in Atlanta.
The 2020 Inform Conference will be from March 9th
through the 12th, and the 2020 Epidemic Intelligence Service
(EIS) Conference will be from May 4th through 7th.
Applications are being accepted
for the David J. Sencer Scholarship
to attend the EIS conference.
We've shared links to recent publications
on several topics including: pool code updates and use
of the model aquatic health code in the local jurisdictions;
rabies outbreak in captive big brown bats used
in white-nose syndrome vaccine trials; and the AVMA guidelines
for the euthanasia of animals, the 2020 edition,
has just been published.
Recent publications in the Morbidity
and Mortality Weekly Report
of interest include Candida auris isolates resistant
to three classes of antifungal medications, New York, 2019.
Notes from the field about the 2019 multistate outbreak
of Eastern equine encephalitis virus.
And a third publication
that just went live a few minutes ago,
the MMWR on the initial public health response
and interim guidance for the 2019 novel coronavirus outbreak,
United States, December 31st, 2019 to February 4th, 2020.
Regarding outbreaks, CDC is closely monitoring an outbreak
of respiratory illness called
by a novel coronavirus first identified in Wuhan,
Hubei Province, China.
Please see CDC's website for more information,
travel recommendations and resources.
A new outbreak of salmonella infections list
to small pet turtles has been posted.
And updates for outbreaks of E. coli infections linked
to romaine lettuce and Fresh Express Sunflower Crips Chopped
Salad Kits have also been posted.
A selected list of ongoing and past U.S. outbreaks
of zoonotic diseases, as well as information on staying safe
and healthy around animals, is available on CDC's healthy pets,
healthy people website.
The complete CDC current outbreak list,
including foodborne outbreaks is available at CDC.gov/outbreaks.
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We've got an exciting lineup of speakers and topics,
and I'll now turn the call back over to Ria.
>> Thanks so much, Colin.
Today's presentations will address one or more
of the following objectives.
Describe two key points from each presentation.
To describe how a multisectoral One Health approach can be
applied to the presentation topics.
To identify an implication for animal and human health.
To identify a One Health approach strategy
for prevention, detection or response
to public health threats.
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You'll find resources and links for all presentations
on our website an in today's ZOHU call email.
I'm now excited to announce our first presentation
which is called Ticks, Tortoises and Tick-borne Relapsing Fever
in the Mojave Desert which will be given by Molly June Bechtel.
Molly, please go ahead and begin when you're ready.
>> Thank you.
So, today I'm going to talk
about a very understudied relationship between a vector
and its host, the desert tortoise, in the Mojave Desert.
I'm going to start by giving some background
on the Mojave Desert tortoise.
The Mojave Desert tortoises are keystone species.
They create a lot of habitat with their burrows for a myriad
of species from rodents to birds to even insects.
Unfortunately, their populations have been declining
since the 80s, and they were listed as threatened
by the U.S. Fish and Wildlife Services in 1990.
Tortoise populations are monitored because in order
to keep tabs on the populations, per government regulation,
and we look for things like clinical signs of disease
as well as other morphometrics just like size
of the tortoise and weight.
Ticks are also often noted
on these tortoise health assessments.
In fact, ticks are known
to commonly parasitize desert tortoises,
and the two species we know
that do commonly parasitize tortoises are ornithodoros
parkeri and ornithodoros turicatae.
They're often called tortoise ticks,
especially in the tortoise literature.
Mostly because they're difficult to identify.
You have to count the number of bumps on the back,
on their backs to be able
to distinguish the two species apart.
Or they're also just listed as ornithodoros species
when they're found on tortoises.
So, these are soft ticks,
and their biology is a little bit different than hard ticks.
They are nidicolous, meaning that they like to be
in dark burrows and dark places.
Tortoises really create excellent habitat
for these guys and their burrows.
They're generalists, which means they're not specific
to one particular species for the blood meal.
They'll feed on anything, any animal that comes their way.
And they commonly parasitize other tortoises.
They're also vectors of the causative agent
of tick-borne relapsing fever.
Tick-borne relapsing fever is caused by a wide variety
of species in the genus Borrelia.
It's a familiar genus because Lyme disease is also caused
by a species of Borrelia.
But I'm going to be focusing on the relapsing fever Borrelia
that occur in the new world.
And you can see the new world clade include three species
of Borrelia, two of which are specialized
with their tick factor, ornithodoros parkeri
and ornithodoros turicatae, that occur in the Mojave Desert
and parasitize desert tortoises.
Both species of Borrelia cause tick-borne relapsing fever
or TBRF in people.
TBRF is characterized by high fever,
around 103 to 105 degrees.
Headache, muscle and joint aches, symptoms very similar
to the flu, except these symptoms will reoccur.
So usually with a fever and other symptoms lasting
for about three days followed
by a febrile period for about a week.
And then those symptoms will return for another three days.
This cycle can occur several times without treatment.
Sometimes symptoms will resolve on their own, but it's treated
with antibiotics like doxycycline.
And this could also occur and passed if they get bit
by a tick carrying relapsing fever group Borrelia,
which is dogs.
These relapses are due to the ability of a Borrelia
to undergo multiple cyclic anagenic variations.
So, what happens is Borrelia invades our antibodies
by switching the surface proteins they express
and become unrecognizable to the immune system.
These relapses can make TBRF difficult to diagnose, but also,
people will go into the doctor, complain of symptoms
that are very similar to the flu,
and they'll be prescribed antibiotics and get better.
And then they're never tested for TBRF.
So, it's thought that TBRF is underreported.
Regardless, ticks are common in desert tortoise habitat
and do come in contact with people, which suggests
that they are a transmission risk.
But very little is known about the ticks in the Mojave,
and even less is known about the relationship
to their host, the desert tortoise.
We do know, though, that about 10%
of wild desert tortoises are sampled are parasitized
by ticks, and almost half
of all active tortoise burrows are invested,
particular with ornithodoros parkeri.
So, we also know that tortoises create habitats for rodents,
which are documented as reservoirs
of TBRF Borrelia group in other parts of the country.
So tortoises may not even be a part
of this transmission cycle other than serving as a source
of nutrition and creating habitat for these ticks.
But the fact remains that tortoise biologists do come
in contact with these tick species as well as hundreds
of pet owners in Las Vegas who have adopted desert tortoises.
And these ticks are competent vectors of a pathogen
that is harmful to people.
So there is a to be addressed of transmission,
and doctors should consider tick-borne relapsing fever.
In fact, we do have two cases to illustrate
that it is a transmission risk.
So the first case study I'm going to talk
about happened in 2017.
This happened to a tortoise biologist that was working
at a study site about two hours north of Las Vegas.
She was out sampling wild tortoise burrows.
She did notice that there were ticks around the burrow,
and about a week after she got home from her field trip,
she became ill with a high fever.
Then the high fever went away after a few days only to return.
So we actually took a blood sample,
and she did test positive for TBRF Borrelia by QPCR.
The second case happened a bit more recently.
Again, this is the tortoise biologist,
except she was working at a captive site near Las Vegas,
and that captive site is pictured
in the middle picture there to the right.
After working in this captive site digging up burrows,
about a week later she did notice that she had been bit
by a tick, and she became ill with a very high fever
and other flu-like symptoms.
And this cycle repeated
until the third cycle actually prompted her to go to the ER.
And because she was aware of the case that occurred in 2017,
she asked the emergency room doctors to test her
for Borrelia, and she did test positive for Borrelia,
and was treated with Doxycycline,
and her symptoms subsided.
So we do have two confirmed cases
of tick-borne relapsing fever occurring in the Mojave Desert
after exposure to these tortoise ticks.
So we want to learn more about the relationship
between this vector and the host, the desert tortoise.
Because these ticks are a risk factor
for not only biologists but, like I mentioned,
desert tortoise pet owners that live throughout Las Vegas.
To shed some light on this relationship,
I analyzed the tortoise health assessments that are required
by the government,
and I analyzed health assessments from 2007 to 2017.
I looked at presence in relation, tick presence,
in relation to tortoise morphometrics, location
and clinical signs of disease.
So I used the GLM and I binned my ticks into categories based
on the range they're given on the health assessment datasheet,
because I'm not asked for an exact number.
So I use a median number for each range.
And in instances where ticks are recorded as greater than ten,
I just use the number ten.
And in rare cases when the technician actually counted the
exact number of ticks that were observed on the tortoise,
I used that exact number.
I also binned clinical signs
into total number of clinical signs.
My initial analysis, I found
that about 8,341 ticks were noted on tortoises
over this ten-year period.
494 of these ticks occurred on tortoises
at the study site Coyote Springs,
which is where case one was exposed to ticks.
But most of them, almost 7,000 ticks,
were noted on tortoises at captive sites.
And this is where case two was exposed to tortoise ticks.
So, from my model, I found that ticks were more likely
to be found on females than males,
and they were statistically significantly more likely
to be found on captive sites
than wild sites, which makes sense.
And as far as my clinical signs go,
I found that ticks were associated more with a tortoise
that has a very low body condition score of three or one
that has a very high body condition of seven,
as well as weak posture and a higher number
of total observed clinical signs.
While fewer ticks were observed
on tortoises with forage evidence.
But what can we glean from this analysis
about tick and tortoise biology?
Well, ornithodoros ticks could be described as lazy,
although they are just really well adapted
for harsh environments like the Mojave Desert.
These ticks stay in their burrows and nests,
and they don't quest like hard ticks do for blood meal.
They're happy to just wait in their dark burrow
for something to come along.
In fact, some ticks have been documented to go for a year
or more without a blood meal.
So it makes sense then that tortoises
that have a higher site fidelity, like females
that don't go from burrow to burrow looking for males
for mates, would have a higher likelihood of getting ticks.
Same goes for captive tortoises and tortoises
that have more cynical signs of disease,
which they just may not be feeling so hot
so they're choosing to stay in their burrows.
But captive tortoises don't have a choice.
So it would seem that if tortoises are
in their normal natural healthy desert environment,
they can scrape off ticks
and choose different burrows, which is good.
Especially because captive tortoises are also more likely
to come in contact with people.
So, to add to this story, oh, and tortoises
with forage evidence, then it makes sense
that they wouldn't have as many ticks observed on them
because they can scrape the ticks off
because they are walking along through the desert looking
for forage, things to eat, so ticks can either be scraped off
as early as in the burrow, or they can decide
to jump ship just because that intense sun is something they
want to hide from.
And they can hide under a rock or a dark piece of vegetation
as the tortoise is wondering about the desert.
To add to the story, we tested ticks collected from tortoises
for Borrelia, and interestingly, we found only 7 out of the
over 900 ticks that were tested positive for Borrelia,
which is less than a 1% prevalence.
It's pretty low, especially considering the density of ticks
that are found in tortoise burrows.
So TBRF is endemic in the West, but very little is known
about the strains that occur in the Mojave Desert.
In fact, this map on the top right corner from Forrester,
et al, includes cases of tick-borne relapsing fever
that were caused by ornithodoros hermsi.
Nothing is known about the prevalence of Borrelia parkeri
and Borrelia turicatae.
So going back to that low prevalence rate
in the tortoise ticks, there is an interesting relationship
that exists between reptiles and ticks in Northern California,
where we see ixodes pacificus, the hard tick,
that carries the Lyme group Borrelia
and causes Lyme's disease and sceloporus occidentalis
of this lizard that occurs in the same habitat.
So what happens is that it's been found
that this lizard has a component in its blood,
and you'll notice it's a Borreliacidal factor
or a Borrelia killing factor.
So when these ticks come up and take a blood meal
from this lizard, the Borreliacidal factor
in the lizard's blood actually kills any pathogen, any Borrelia
that that tick may be carrying.
So it leaves that tick incapable of transmitting disease
because the Borrelia has been killed.
So, what's really cool about this is in areas
in Northern California where we see more lizards,
we actually see fewer infected ticks.
And this Borreliacidal factor is related
to a thermal lay bioprotein that does occur
in reptiles such as tortoises.
But no research on resistance or susceptibility
to tick-borne disease in desert tortoises exist.
So this research is really just scratching the surface of ticks
and tick-borne relapsing fever in the Mojave Desert,
but we'd like to learn more about the relationships
between tortoises and ticks.
Rodents also share burrows, as I mentioned, with tortoises.
So we don't know if they are helping to maintain the pathogen
and tortoises are creating this perfect habitat
for a potential reservoir hosts as well as the ticks.
Which would help maintain Borrelia in the system
or if they do have a Borreliacidal factor
in their blood, like the lizards in Northern California,
and are helping to keep Borrelia at a very low prevalence.
Regardless, we know
that tick-borne relapsing fever cases may increase
as people continue to encroach on the Mojave Desert,
and research to better understand the somatic disease
dynamic is important to maintaining public health
and potentially to help conserve populations
of the threatened desert tortoise.
So with that, I'd like to thank all of my collaborators
and funders as well as the Zoonoses
and One Health Updates call for giving me the opportunity
to talk about this cool research.
>> Thanks so much, Molly.
That is indeed very cool research.
So our next presentation is 2019 AAFP Feline Zoonoses Guidelines.
And this will be given by Michael Lappin.
Michael, when you're ready, please begin.
>> Thank you very much.
That was a great first talk, and I'm quite honored
to be on the call today.
This is my first experience, even though I've gotten to work
with the CDC in a number of different ways over the years,
including with our WSAVA One Health committee,
which I'll talk about in a few minutes.
But certainly, anyone has follow up calls,
I believe Helen has made the email address available already.
Please follow up as indicated.
I direct the Center for Companion Animal Studies
at Colorado State, which is a nonprofit that's really our
mission is to promote research by young people.
We fund a number of seed money grants
to help people do clinical.
Usually non-fatal research.
But today I'm serving as a representative
of the American Association of Feline Practitioners.
As you can see, I'm a DVM.
My PhD is in parasitology, and I'm board certified
in small animal internal medicine.
This particular call does not have any direct competition
or any conflicts to report,
but I do always thank all the different sponsors
of our student granting projects,
the Young Investigator Awards for giving gift money
to help promote research
by the next generation of veterinarians.
So for today I'd like to introduce you
to our WSAVA One Health committee.
Michal Day from Bristol was our founder.
It was his dream to have this small animal group be more
active on the world stage for One Health issues.
If you're not familiar with our group,
we now have over 120 member countries or delegations
around the world, and because of the AVMA being part
of our group, that puts us over 200,000 veterinarians
that we contact, hopefully, with our work.
Casey's been our representative for the CDC since the inception
of this particular endeavor, and as you can see,
we currently have two medical doctors that serve
with William working mainly with comparative oncology and Chand,
who's a DVM, is the other part of comparative oncology.
Peter is an MD in Rhode Island that just happens to be married
to a feline specialist,
so he does recognize the health benefits of pet ownership.
So this particular group has been involved
with the AAFP zoonoses committee, which we'll talk
about today indirectly as well as directly.
So, for example, Peter co-serves on our AAFP zoonoses guidelines,
as well as our One Health committee.
And as we develop these guidelines,
which are the second edition.
The first edition was over ten years of age,
so we felt that it was time to refresh these.
What we've done with our guidelines,
if you're not familiar with the AAFP,
which by the way is catvets.org.
If you're not familiar with our guidelines,
we tend to find topics that we believe are important.
We often co-sponsor with the International Society
of Feline Medicine, or we will co-certify each
other's guidelines.
This particular document, Carol Glasser from Pediatric AIDS
in San Francisco in the old days,
Carol was a repeat medical doctor that's also a doctor
of veterinarian medicine on this particular document.
Bottom line is then a group of these feline specialists
or feline-interested individuals.
Then we interact with attempting to come up with a document
that we feel is probably most commonly read by veterinarians.
But we are attempting to advance our One Health mission
by interacting more closely
with our especially primary care physicians.
This particular page is just to point out that this document
when we had finished
at the committee level had approval from our board.
We also then asked the Companion Animal Parasite Council,
which is one of the parasite groups in the United States,
WSAVA, and the International Society of Medicine,
to evaluate the document for accuracy for one thing
and then also to whether or not they wanted
to state an endorsement.
The messages that I wanted to get across to the group today,
which I know has a great mix of different types of scientists,
is that practicing veterinarians,
they have to know many different things, multiple species,
infectious diseases, and One Health issues is obviously not
or only thing that we need to focus on in our practices.
So it's great that we have such excellent resources
like the capcvet.org for the American parasite guidelines.
The ESCCAP group has had theirs translated
into several different languages, very similar
to the American guidelines, and all the great work
that the CDC has done with healthy pets, healthy people,
and that's been great to interact
with that team, including Casey.
So that's one of my most important go-to sites
when I'm working with my lay people owners of cats.
And then, of course, Bayer has done a nice job
with their CVBD site.
If nothing else are world occurrence maps
for when animals come into the United States
and we don't actually know,
a practicing vet might not know what vector borne diseases were
endemic in that country.
Those worldwide occurrence maps are quite helpful.
We also work with the other publications from the NIH,
other federal agencies.
AIDS info has been used, you know, quite frequently
by our group and others over the years trying to really educate
that variance for the most part.
And then make sure that our veterinarians and physicians
that are helping these family units, folks that own cats are
on the same wavelength.
Some of the graphics that have been developed are just
fantastic and really, I think, is very helpful
in helping people understand
that they can potentially enjoy the health benefits
of pet ownership but still trying
to avoid those real potential zoonotic issues.
So again, from the cat side of things being an AAFP member,
I've got to admit our side is that pets are good,
cats are good for you.
And we certainly encourage and applaud those
that have been studying, you know,
the benefits of pet ownership.
My wife's a veterinarian as well,
and we both have agreed well,
we're in our 20th season together, to own four dogs
and four cats at any one time.
And we've kept that pact for a long time.
But we also realize that there are health risks
from those kitties, and we have to be careful as, you know,
our lives change and perhaps health issues develop.
But what we believe from the AAFP side of things,
and I hope this is the message that you'll get if you read
that document that should be posted as well with the slides.
We really would like to strengthen that interaction
between physicians, veterinarians and the family.
I think we all are familiar with some of the misperceptions
of risk of individual cats for say acquiring say toxoplasma.
Gosh, in the early days of HIV and certainly for a long time
with pregnant people, a lot of folks, you know,
assumed that you could increase your safety level
by not owning cats, but not concurrently, reminding people
to wash their hands after gardening
or to wash their produce well.
So I think our goal from AAFP and this document
in particular is to at least try to have accurate information
to the readers of the document to help people at least start
on this even playing field when giving owners advice.
What I personally said myself many times is I don't tell
people to own cats or dogs.
I don't tell them to get rid of their cat or their dog.
But if there is a health issue that might relate
to pet ownership, I believe
that we should give them accurate information
so the family unit can make their decisions.
And of course doing that,
working with the physician directly would give us the
most strength.
So our goals from the feline internal medicine
or feline practitioner side of things is really to make sure
that our lay persons realize that animals that are sick,
if their cat has clinical signs of disease of any flavor,
they could potentially have something
that would be a little bit more likely
to be shed to a family member.
And so our goals are just to make sure that our folks realize
in the sick animal arena to allow us
to do the appropriate test diagnostics consultations.
And in the wellness side of things, we certainly would
like our owners to allow us to provide our strategic deworming,
our flea and tick control that could help
with potential shared vector zoonoses.
And then, of course, our goals with the vets are to make sure
that veterinarians realize that if animals are sick,
they're a little bit more likely
to be potentially a zoonotic health risk but also realize
that there is benefit to flea tick preventative measures.
Obviously, rabies is our biggest worldwide problem, that we want
to make sure that countries
that don't have current prevention programs get
that stepped up over time.
And then again, as I've emphasized
on the previous slide, I think one of our biggest messages both
from AAFP as well as WSAVA is that the veterinarian half
of the family medical support would certainly love
to work more closely with the physicians
in a One Health arena.
What we did with our document, both versions,
including the 2019, which by the way just came out in December,
so a fairly new document for us.
We've gone ahead and talked
about the animal contact zoonoses.
Again, we believe that veterinarians are interested
in what they might catch at work.
And then of course, pet owners are very interested
in what they might acquire from touching their cat.
But we do spend time talking about contaminated vehicles.
Shared vectors, of course, are emphasized a lot,
especially with the bartonella issues.
And then shared environments, we make sure that we have
at least some discussion about many
of these zoonotic diseases are not acquired
from touching the pet directly but acquired
from that shared environment.
So just to give you a couple of examples,
if you haven't had a chance to review the document yet,
we then have a specific table for each
of those major direct zoonoses routes of transmission
and then have just a few words to remind people
of the most common agents, what you might suspect
in an animal infected with that particular agent
and then the concurrent illness in people.
And then what we've done, again, because this is
for primary care feline practitioners as well
as veterinarians in general, we did attempt
to make some callouts for some of our more important things
like the example I shared on this slide.
All of our panelists were quite keen on feeding processed foods,
especially if there's family members
with immune deficiencies.
This particular table is just one of the examples
of the starting of the list of the bite, scratch
and exudate associated organisms.
Certainly, since we touch more cats than most,
we certainly have to be cognizant as veterinarians
that bite wounds be managed appropriately.
In fact, one of my research technicians today just got a
nice kitten bite earlier this morning.
So she has already returned from urgent care, thankfully.
But we also try to get other points
across that have been generated by the CDC and others like that.
Kind of a rumor amongst veterinarians that's kind
of driven by one laboratory that perhaps we should be testing
and treating all kittens for bartonella.
And that, of course, goes against our judicious use
of antimicrobial guideline statements.
So we certainly pulled that one out as a callout
for that particular organism.
So as you read through the document,
we certainly look forward to input, especially from CDC
and folks that would be on some type of call.
We've then tried to summarize some of the general guidelines
and one table for veterinary staff members
and then a second table for owners.
And then the AAFP, we do like to make brochures and things
that are available for distribution to clinics and also
to owners to supplement what we might see on healthy pets,
healthy people at the CDC.
We consider you guys to be the gold standard
and appreciate the opportunity to work
with Dr. Behravesh on those things.
So bottom line is we try to get that message
across that clinically ill cats should be seen.
Healthy cats are relatively safe,
especially if you wash your hands a lot,
feed processed foods, clean the litter box daily, etcetera.
And continue to try to interact more
with our physician colleagues to spread the word.
So, so far I think we've gotten the point across hopefully
that we believe at the AAFP level that most pets are safe,
in the cat world especially, specifically with AAFP.
However, there are things that are shared, so we are attempting
to continue to partner with groups like WSAVA.
And Michael headed this up.
He was the chair of the committee
at the time we published this paper.
And I always lovingly call this the other AAFP being the
American Family Physician group rather than the cat group.
And we were quite pleased to have one
of our dual publications in that particular journal.
And we'll continue to try to spread that word.
One way that we're doing that is
with the One Health certificate course for veterinarians,
and we do allow animal technicians
to take this course as well.
In the United States, the groups of lecturers are RACE certified
so that veterinarians can get CPD credit.
I certainly would love any interactions
from those on the call today.
If you'd like to visit the website, we're hosting
that at CSU just because we actually have a system
to do that, but it is a WSAVA endeavor.
We have a number of One Health modules that still need
to be recorded, and we look forward
to having all 20 of these online.
And what we're doing with the veterinarians
that are interested, they can earn a certificate
by completing all the modules, and that can be displayed
in their veterinary clinics showing
that they have an interest in expertise in One Health.
So thank you very much for listening today.
I look forward to the next talk and then questions
at the end or follow up emails.
Thank you.
>> Thank you so much, Michael.
Our final presentation is Community-Based Prevention
of Epidemic Rocky Mountain Spotted Fever Among Minority
Populations in Sonora, Mexico, using a One Health approach,
and it's going to be presented by Anne Straily.
Anne, please begin when you're ready.
>> All right, thank you for that introduction.
So this is a project that I was fortunate enough to work
on as an EIS officer with [inaudible] zoonoses branch.
I've since moved on from the [inaudible] zoonoses branch,
so I'm giving this presentation on behalf of my colleagues
in RSV and also in Sonora, Mexico who are unable
to make today's ZOHU call.
So rocky mountain spotted fever or RMSF for short is caused
by the obligate intracellular bacteria rickettsia rickettsii,
which likes to infect endothelial cells lining the
blood vessels which when damaged become leaky and results
in a widespread vasculitis.
So the picture at the bottom right-hand corner there
demonstrates the endothelial cells of a blood vessel
which is cut in crossed section containing the rickettsia
rickettsia bacteria, which is stained red.
RMSF is a tick borne illness, and it is treatable
with doxycycline, but treatment really needs
to be initiated early in the course of illness
to obtain the best outcome.
Early symptoms, unfortunately, are fairly nonspecific,
things like fever, headache, muscle pain,
all of which can be easily confused with other diseases.
So on the next slide I'm going to show you some pictures
of what advanced severe RMSF looks like.
I should warn you that some of these pictures can be graphic.
Without timely treatment with doxycycline,
RMSF progresses rapidly.
Extensive vasculopathy results in necrosis and gangrene,
which often requires amputation of digits or limbs.
Other long-term sequelae can include neurologic complications
such as cognitive impairment or hearing loss,
peripheral neuropathies, cerebellar
or vestibular motor dysfunction, just to name a few.
Death occurs due to multiorgan failure
and disseminated intravascular coagulation,
and case fatality rates without timely treatment are around 25%.
Epidemic RMSF is associated with massive infestations
of the brown dog tick, Rhipicephalus sanguineus,
which is pictured here.
The brown dog tick has actually been recognized as a vector
of RMSF in Mexico and the American southwest
since the 1940s.
The dog is the preferred host for all life stages
of the brown dog tick, but the tick will also readily invest
human dwellings and kennels when it's not on the dog,
and the red arrow here is pointing to a tick
that was spotted on the wall of a house
in our intervention area.
So dogs can be heavily infested with ticks,
like in the photos here.
And actually, each one of the little black spots
on the brown puppy in the picture
on the right there is a tick.
And again, another picture of a dog heavily infested with tick.
Each one of those little gray blubs
on that dog's ear is a tick.
So these heavily infested dogs support large populations
of ticks in very close proximity to humans.
And the warm climate in Mexico provides a suitable environment
for ticks to be active year-round.
So this isn't a seasonal problem.
As a result, the ticks are everywhere.
They're in the houses.
They're in the yards.
They're on the dogs.
They're almost impossible to escape.
And humans are bitten as a result of contact
with tick-infested dogs or tick-infested environments.
And kids are especially at risk of exposure
because they have increased contact with dogs
and spend more time playing in spaces
where ticks live, like in the yard.
So in case you're unfamiliar with where Sonora is,
Sonora is a state in Northwest Mexico which is outlined here
in red, and it borders the U.S. states of Arizona
and New Mexico to the north.
During the time period from 2004 to 2016, there were almost 1,400
of RMSF cases reported in the state of Sonora
with 250 deaths almost.
Seventy-five percent of those cases corresponded
to people living in disadvantaged neighborhoods.
Between 2009 to 2015, there was one small impoverished community
in particular that was severely affected by RMSF.
They had median accumulative incidence rates
of 29 cases per 100,000 people,
which is around six times the median accumulative incidence
rates for the rest of the state.
Three-quarters of those cases occurred
within just a ten-block area
that consisted of 703 households.
So quite a focal occurrence there.
In 2015, the Mexican Administrative Health actually
declared RMSF an epidemiologic emergency.
So this is a picture of community A. The community A is
that severely affected ten-block section that we talked
about on the previous slide.
It's part of a larger but still impoverished rural community
that's located about 50 miles from Hermosillo.
Community A is inhabited predominantly
by agricultural laborers with a majority
of migrant families coming from Oaxaca and other states
in the south of Mexico.
So community A was selected as our intervention community.
Community B which was selected
as the control community is an impoverished suburban community
of about 730 households that located
on the outskirts of Hermosillo.
It was selected because it was geographically isolated
from community A, which was important
to limit the possibility of intervention bleed over but also
because it was highly impacted by RMSF,
although not necessarily to the degree that community A was.
In fact, no other community was hit quite as hard by RMSF
as community A. So community B experienced six cases
of RMSF during 2009 to 2016, three of which were fatal
and one of which occurred in a child.
So now we're going to take a closer look at the intervention.
The goal of which was to reduce the number of human RMSF cases.
The intervention was designed using a One Health approach
with components targeting animals,
the environment and people.
We sought to control ticks on dogs, control ticks
in the environment and educate people
in the community about RMSF.
So if this sounds familiar,
it's because this approach was modeled off a very successful
intervention that was previously used in Arizona.
So component number 1, control ticks on dogs.
Each dog received two collars, like you see in the photo here.
The gray collar is the tick collar.
This is a collar that contains flumethrin and imidacloprid.
It provides tick control for up to eight months,
and it actually holds up pretty well in a desert environment.
Dogs have to be at least eight weeks old,
and it has to be fitted and worn correctly
for maximum effectiveness.
The red collar is just a simple nylon collar.
It was provided so that people would not attempt to handle
or restrain dogs using the gray collar, because the gray collar,
the tick collar, is actually designed to break off
if the dog struggles against it.
The red collars are also a fairly handy and visible marker
that dogs are participating in the intervention.
So puppies less than eight weeks of age and therefore too young
to receive a collar were instead treated with fipronil spray,
and they were aged based on their dentition.
Component number 2, control ticks in the environment.
Participating homes received pesticide applications
with deltamethrin on a bimonthly basis.
The deltamethrin was applied by vector control operators
with the Sonora Department of Health,
and homes were sprayed inside and outside,
and the adjacent yard areas were also treated.
Component number 3 was to educate the community.
So here we developed a pictorial bifold pamphlet
to use in this area.
Literacy is quite variable in this community, and Trique,
which is the indigenous language which is spoken
by many residents in community A is actually not a
written language.
So we had community health workers that spoke Trique
that were available to translate for households
that did not speak Spanish.
These pictorial pamphlets covered how RMSF is translated,
the signs and symptoms of the disease, when to seek care
from the health clinic and how to prevent it.
So it wasn't ethical to just do nothing for community B,
our control community, given how serious RMSF is.
So community B continued
to receive the standard RMSF prevention activities used
by the Ministry of Health, which includes community education
and environmental acaricide treatment of home.
I should also mention that the larger town outside
of the ten-block area that made up community A also continue
to receive the MOH standard of prevention
for RMSF during the stay period.
So the real difference here between the intervention
and control communities is the provision
of tick collars on the dogs.
There were a number of different measures
that we collected during the study.
We did a pre and post knowledge, attitudes and practices
or KAP survey that collected information on a number
of different things, including dog ownership practices,
tick contact and awareness of RMSF.
We also visually inspected a systematically selected random
sample of dogs for ticks.
And these tick counts were categorized as no ticks seen,
one to ten, 10 to 100 and over 100 ticks.
The study took place during March to November of 2016.
So beginning in March, we registered homes
and collected the pre-KAP survey data.
We did the first environmental acaricide treatment,
and in community A we enrolled dogs
and applied the tick collars.
We went back to both communities in May, July and September
where we did the tick burden, the monitoring
of the tick burdens on dogs,
and the participating homes received another round
of acaricide treatments.
In community A specifically, we also replaced lost tick collars
and gave new dogs new collars during each of those visits.
And finally, in November,
we collected the post-KAP survey data
and did a final tick count on the dogs.
So we don't have time to go over all the results,
so for today's presentation I'm just going to focus
on the measures of tick contact
and the visual burden of ticks on dogs.
The first result that I want to highlight is the number
of households of dogs with dogs with ticks.
So both community A and B saw a decrease
in visible tick infestations on the dogs.
But it was only in community A which is the purple line here
where that decrease was statistically significant.
So in community A at the beginning of the study,
a full one-third of households had a dog with ticks,
and that number decreased to only 9% of households
by the end of the study.
The second result that I want to highlight is the report
of tick activity by homeowners.
So we asked participants if they saw ticks in their house,
which is denoted by the orange line, or in the yard,
which is denoted by the green line.
And in community a, which is the solid line,
both of those measures actually decreased significantly while
in community B, which is the dashed lines,
both of those measures actually increased during the study.
So there were far fewer households in community A
that reported seeing ticks in their house or in their yards
at the end of the study compared to the beginning
and also compared to community B. So we'll finish
up with perhaps the most important result of all,
which is the number of human RMSF cases.
So in community B, there were two confirmed cases
of Rocky Mountain Spotted Fever
and one death reported during the study period.
While in community A, there were actually no cases
of human RMSF reported during the study period.
And in fact, there were no human cases of RMSF reported
in this area until April of 2018 which is a full 18 months
after the study ended.
So in conclusion, we were able to demonstrate
that this One Health approach successfully prevented RMSF
cases in a high-risk, heavily impacted
and impoverished area of Sonora, Mexico.
So each element in this strategy really contributed
to a decreased number of dogs with ticks, decrease the number
of ticks that people saw in their house or in their yard
and also contributed to an increased awareness
of RMSF in the community.
And all of these different components together resulted
in a decreased number of human RMSF cases and deaths.
So that's all I have for you today.
Thank you so much for your time and attention.
>> Thanks so much, Anne.
It's always great to see those types
of One Health approaches occurring in the field.
At this time, we'd like to take questions
from any of our presenters.
If anyone in the audience has a question,
please call 1-800-857-9665
and enter participant passcode 6236326.
Press star one and give the operator your name
and affiliation.
Please name the presenter or topic
at the beginning of your question.
So Brad, do we have any questions yet?
>> And once again, that is star one.
If you are already on the phone, please press star
and then one at this time.
One moment, Miss, while we gather questions.
We have Christina Nelson from the CDC.
Miss Nelson, please go ahead with your question.
>> Hi everyone.
First of all, I just want
to say the ZOHU call always has good speakers,
but the speakers today were particularly excellent.
I really enjoyed all of these presentations,
so thank you to everyone.
My question is specifically for Mike Lappin.
I know you mentioned that for cats for owners
who are immunocompetent it is not recommended
that veterinarians test or treat for bartonella
if the cats are asymptomatic.
For immunocompromised owners, my understanding was
that the recommendation is still the same.
That, you know, if the cats are asymptomatic
and the owners were doing okay, asymptomatic in terms
of no evidence of cat scratch disease or other things,
then the cat still should not be tested or treated
from bartonella because, you know,
it's hard to give antibiotics to the cats.
And sometimes the owners get scratched when they're trying
to give the antibiotics.
So I was just wondering your comments on that,
have any recommendations changed and any other thoughts.
>> Yeah, so thank you for the kind comment about the lecture.
I certainly enjoyed the other two a lot.
And to directly answer this question, we follow the lead
for the CDC of course and aid them though in pet ownership
by immunocompromised people.
And I support those recommendations.
Honestly, doing something like soft claws
and bleed control is probably going to control the majority
of zoonotic transmission of bartonella by flea
or dander or scratches.
And so our group the AAFP, a group of veterinarians,
we don't support testing and treating cats
of immune suppressed families in general.
However, the caveat always does come up is what if they walk in
and they say they've heard about bartonella,
and my cat has had fleas.
I'm going to relinquish the cat unless I know.
And in that case, you now,
I believe that most veterinarians would go ahead
and test, even, hoping for negative [inaudible]
and negative PCR so that we can then just put that to bed.
Because, gosh, my clients, well I practiced in Georgia,
Oklahoma, California and 30 years in Colorado.
You know, one thing though, even though they know there's,
even though we tell them there's probably little risk,
once they know they're having antibody positive or whatever,
they do want to treat.
So again, I think our overall recommendation would follow
exactly the CDC's which is there's probably no indication
that test healthy cats of any family,
but all families should do flea control
and avoid bites and scratches.
>> All right, okay.
Thanks Mike.
That's very helpful.
>> Once again, if you have a question and would
like to ask it over the phone, please press star
and the one at this time.
Please stand by for any further questions from the phone.
And once again, that is star one for questions over the phone.
One moment please.
Next, we have Dr. Pat Kline from the USDA Forest Service.
Please go ahead.
>> Yeah, hi, good afternoon.
This is Dr. Pat Kline from USDA Forest Service.
My question is actually for Dr. Lappin as well.
I've actually had an opportunity
to read the new zoonotic guideline,
and it's very well done.
I had one quick question if I could get some feedback
from you regarding cats and toxoplasmosis.
We do recognize that the litter
of the cat is the definitive host, and as you were explaining
in your guide, yes, oftentimes the exposure to humans is
through environmental exposure route.
So, how does AAFP stand, or what's your position
on advocating to keep your cats indoors,
I mean all of your pet cats for all the right reasons in a way.
But also to not add to that environmental burden
if they're going to be shedding toxoplasmosis
in the environment?
Would you make any comments on that please?
>> Yes thank you for that great question.
Now, I did not serve on any
of the cat wellness committee work from AAFP.
I've just been with the zoonoses and vaccine guidelines.
But you may know some of the listeners today.
There's kind of a large push from some feline practitioners
and that, you know, cats should be allowed to go outside.
And so that particular, you know, discussion,
is kind of a hot button amongst our team.
And, you know, with the tradeoffs of, you know,
cats behaviorally want to be outdoors,
whereas indoor cats live longer.
Don't pass toxoplasma environment, don't eat,
you know, hundreds of birds per year.
You know, there's lots of great discussion on both sides.
So our committee stayed a little bit out of that fray.
But certainly, it's well established
that it's not just domestic cats.
They can complete the lifecycle of the organism as well.
So confining all cats indoors, you know, in theory,
would hopefully lessen the world's outdoor burden
of toxo OSS, but it probably wouldn't eliminate it
because of other, you know, competent felids.
>> Thank you for that.
And by the way, I've owned cats for 30 years, and I adore them
as much since I'm a veterinarian as well.
But none of my cats go outdoors.
And I'm lucky because they've lived to be 18 and,
you know, 20 plus years.
So, I really love cats.
I'm just looking out for their best interests as well.
Thank you.
>> Yeah, great comment for that.
We love ours as well.
And we kind of have the compromised position
that we actually have an outdoor cat run.
But they do ingest birds, bunnies and rodents
and one snake in their outdoor cat run.
So they weren't eaten by the coyotes,
but they've certain eaten their share of other creatures.
So I should probably test the soil there in their cat run
to see if there's [inaudible] OSS.
>> Thanks for your questions.
We're going to wrap up now.
But if you do have additional questions,
you can also email the presenters.
You'll be able to find their email addresses
on the ZOHU call webpage for today's call.
So I just wanted to say thanks again for all
of today's speakers, for their excellent presentations
and give you a few instructions on continuing education.
So, you can receive free continuing education,
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at CDC.gov/onehealth/ ZOHU/continuingeducation.
And the course access code is onehalt2020, all lowercase.
To receive free CE for today's webcast, complete the evaluation
at CDC.gov/PCEonline by March 9th, 2020.
Our web on demand recording
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by March 10th, 2020.
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Thanks again to everyone for your participation,
and we will now end today's call.
Thank you.
>> Thank you all for your participation
on today's conference call.
At this time, all parties --