An hour and several laboratory diagnostic tests later, it was clear: this little primate was severely anemic and in need of a blood transfusion. My only choice was to obtain a donation from an adult in our existing group of spider monkeys. Several hours later, I crossed my fingers and started her transfusion. Fifteen minutes into the procedure, she became a new monkey! I had to hold and entertain her for the remaining one and a half hours of the transfusion to keep her in one place. Subsequently, she grew into a strong adult and never looked back. 

Many veterinarians have witnessed the incredible power of transfusion medicine like I did with my little spider monkey patient. However, transfusion medicine is actually not new. The first known successful blood transfusion occurred in 1665 in England when Dr. Richard Lower transfused dogs with blood from other dogs in order to keep them alive¹—that’s right, animal research for the win! 

Following Dr. Lower’s success with dog-to-dog transfusions, Dr. Lower and Dr. Jean-Baptiste Denis in France recorded successful transfusions from lambs to humans. However, when Dr. Denis’s fourth transfusion patient died, his surviving wife accused the physician of murder. Although the doctor was cleared of the charge in court, the court also banned blood transfusions because of the rate of adverse reactions, and the rest of the world soon followed suit.² 

The 1800s saw continued efforts in refining transfusion medicine, including the first human-to-human blood transfusions to treat postpartum hemorrhage and hemophilia. In the late 1800s, U.S. physicians were using milk from cows, goats and humans instead of blood for transfusions. As one might imagine, transfusion reactions to milk were frequent and severe, so saline replaced milk as a “blood substitute.” 

The turn of the century brought about the recognition of different human blood groups and efforts to cross-match prior to transfusion in order to avoid adverse reactions. Once anticoagulation compounds and refrigeration were integrated into the storage and handling of blood, early blood depots were utilized to save lives during WWI. And, in 1932, the first blood bank was established in Leningrad hospital. World War II saw the emergence of albumin transfusions (rather than whole blood) to treat shock in victims of the attack on Pearl Harbor. 

In the 1950s, the plastic bag for blood collection and the development of a refrigerated centrifuge allowed for more precise blood component therapy. And, as recently as the 1980s, the era of transfusion medicine began and doctors could be trained specifically in blood transfusion for patient care. From there, the growth of blood component therapy continued to soar. 

In one of the latest developments to allow for even greater shelf-life and use in austere settings, the FDA issued an emergency use authorization to allow the U.S. military to use freeze-dried plasma to treat hemorrhage in combat settings in 2018.

While veterinary medicine may not yet have reached the point of transfusion medicine as specialty or administering freeze-dried blood components, transfusion with blood products has seen some incredible changes in the last 50 years. For most practitioners, the blood donor dog living in the clinic is long gone and has been replaced with either a list of client-owned dogs available for presentation and blood collection when necessary, or use of a commercial veterinary blood bank. 

Typically, client-owned donors are provided free or discounted preventive care and blood-borne disease screening with a nominal payment for each donation, but programs vary significantly among clinics. What seems far more interesting is the emergence and rapid growth in commercial veterinary blood banks.

The Association of Veterinary Hematology and Transfusion Medicine currently lists 12 veterinary-specific blood banks in operation with one of those being exclusively feline.³ While the exclusively-feline blood bank harvests blood from cats owned by shelters prior to their purchase by new owners, other facilities use either client-owned pets or have on-site colonies and kennels from which to harvest blood. Many, if not all, facilities with on-site donors have a program by where the animals may find a home in the community following their retirement from donating blood. 

Some states, like California, control animal blood banks with significant regulations such as requiring licensing fees and recently allowing for transition to “community animal blood banks” utilizing “volunteer” donors from the community, etc.⁴ However, most states do not address animal blood banks, making it prudent for practitioners to do their own research in selecting a bank to work with. 

Most commercial veterinary blood banks not only provide blood components, but also offer support to practitioners in the form of ancillary supplies for transfusions and guidance on appropriate administration, as well as other clinical advice. For the general practitioner who performs transfusions less commonly than their emergency and urgent care colleagues, technical support from those better versed in transfusion medicine can be critically important to clinical success. Indeed, proper selection of pre-transfusion diagnostics, clinical indications for component therapy versus whole blood administration and adverse event mitigation are all key to a successful clinical resolution. 

Veterinary transfusion medicine has become incredibly advanced in the last 20-30 years and, in this clinician’s opinion, practitioners should consider moving beyond the “donor in the back of the clinic” paradigm and engage the services of a professional veterinary blood bank. 

Now, if veterinary blood banks could just accommodate spider monkey-specific components… +

References:

1. Highlights of Transfusion Medicine History. Aabb. https://www.aabb.org/news-resources/resources/transfusion-medicine/highlights-of-transfusion-medicine-history

2. The Strange, Grisly History of the First Blood Transfusion. Encyclopedia Britannica. https://www.britannica.com/story/the-strange-grisly-history-of-the-first-blood-transfusion

3. Veterinary Blood Banks. AVHTM. https://www.avhtm.org/resourceslinks

4. AB-1282 Veterinary Medicine: Blood Banks for Animals. (2021, Oct, 11). California Legislative Information. https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=202120220AB1282

The post Take It to the Bank: The Advancement of Veterinary Blood Transfusions appeared first on PetVet Magazine.

Wait, what?! No mention of rabies prevention?! 

Justification would seem obvious as rabies is a significant human health concern and canine rabies has been eradicated in the US for decades following effective policies legally compelling vaccination and eliminating stray populations. However, digging just a bit deeper into the issue provides some startling and disturbing facts surrounding rabies, animal movement and resulting animal welfare. Let’s start with canine rabies…

In 2007, the CDC officially declared the US free of canine rabies.² The announcement represents the culmination of years of hard work and is the result of a multifactorial approach to a serious public health threat. Rabies remains nearly 100% fatal in most, if not all, species susceptible to infection. In fact, at least 60,000 people die from rabies annually and most are children infected with canine rabies from a dog bite.³ 

A key characteristic of rabies is that the virus exists as different strains or types that are named according to their maintenance host in which the virus is adapted to survive and as an indicator of transmission. For example, raccoon rabies is specifically used to refer to a strain that is maintained in raccoon populations, thus, raccoons may survive for extended periods following infection and successfully transmit the virus to others to maintain the virus in their population. 

Rabies is most frequently transmitted via a bite as the virus is shed efficiently in saliva of infected hosts. The virus then remains in the local bite site for several days before traveling through the nervous system to the brain and then into the salivary glands. Rabies has two distinct clinical syndromes: paralytic (or dumb) and furious. However, both are nearly 100% fatal once symptoms appear. 

The most effective “treatment” for rabies in any species is prophylaxis prior to the onset of clinical symptoms. If vaccinated prior to exposure, patients require less post-exposure prophylaxis and externally administered immunoglobulin is not indicated. 

Each year, ~55,000 people are treated for rabies exposure in the US with cost ranging from $10,000 to $100 million per person, depending on exposure, wound care, intervention timing, etc.⁴ Total public health expenditures on rabies prevention and control in the US tops out at an eye-popping $245-510 million annually. A recently imported rabid rescue dog cost the federal government a whopping $215,000-$509,000 to investigate.⁵ Currently, the companion animal vaccine is perhaps the cheapest vaccine available and, once again, confirms that prevention is much, much cheaper than a cure. 

Rabies is surely a concerning disease, but how often are companion animals or other species actually traveling internationally and being imported into the US? 

According to a recent report by the USDA, more than one million dogs are imported into the US each year.⁶ This includes those declared as personal pets by the owners and those imported for distribution and resale through all outlets (shelters, rescues, breeders, etc.). The majority of these are assumed to be personal pets; however, assumptions are less than ideal when discussing disease vectors. 

Importation permits for dogs are fairly simple and variables are based on country of origin. Generally, a simple health certificate is all that is required. In fact, with changes in the last few years to the CDC requirements, 75% of all imported dogs are exempt from any rabies certificate requirements. Contrast these facts with the significantly more complex process of importing almost any other species into the US, as most require multiple serological tests, immunizations and permanent ID placement, and are visually inspected by officials upon entry into the US, with some species further requiring significant quarantine at great expense (and risk) to the importer. 

Beyond these minimal requirements for dogs to move around internationally, what about the welfare implications—not only for the dogs in transit but for the dogs already in the US?

Roughly 1.5 million animals are killed at US shelters every year which is more than the estimated total dog imports from the USDA’s 2018 report.⁷ It is simplistic to believe all dog imports are by traditional pet stores or even breeders. Importing dogs to “rescue” them is a rapidly growing industry with apparently mortal consequences for local resident pups. For example, one such organization states that they have imported 600 dogs from China over the last two years for the purpose of rehoming them in the US.⁸ The organization states that the cost to bring each dog to the US is $2,500-$3,500. That’s per dog! While all personnel involved are said to be volunteers so that all funding is consumed by operations, that’s a lot of money for each dog. This organization is based in a county with a population of ~100,000 and the county animal shelter has dogs available for purchase (adoption) for a mere $85 and estimates $460 spent per animal.^9-11 If the rescue organization shifted focus to animals within their home community, an additional 3,300 American dogs could be saved. Additionally, China is currently categorized as a “high risk” country for rabies by the CDC¹² and considered an incubator for influenza. Surely avoiding euthanasia is the pinnacle of improved animal welfare?! 

While the CDC claims the temporary change in importation policy is a response to the number of dogs denied entry that have poor outcomes awaiting shipment home, one may wonder if the dramatic increase in the number of imported dogs testing positive for rabies after arriving in the US and the number of people involved in likely exposures to the nearly 100% fatal virus is also a contributing factor? 

As a veterinarian routinely administering rabies vaccinations in practice, this approach would make perfect sense. For a pathogen with a near 100% mortality rate in dogs and humans (and many other species), caution seems minimally prudent. This policy might also inspire all shelter pets in the US to rejoice! 

A commonsense presumption would be that if rescue organizations and shelters are actively seeking to import stray dogs for resale (adoption), then all shelters in the US must be empty or, at the very least, have euthanasia rates nearing zero? Must we look abroad for homeless pets? What a champagne problem! 

Importing cattle from foot and mouth disease (FMD)-endemic countries is far more difficult than importing dogs from canine rabies-endemic countries—and FMD is not lethal to humans. FMD is considered a foreign animal disease not currently present in the US. Canine rabies is considered not currently present in the US. Should importation policies not be applied equally across species in order to maintain these hard-fought (and expensive), disease-free designations? 

The change in policy is not only perplexing in and of itself, but the early warning of the implementation is equally disconcerting as it allowed for circumvention of the targeted outcome. Following the CDC’s announcement of the future effective date of the ban, overseas rescues use the announced implementation date to ramp up efforts to ship as many “rescue dogs” into the US as possible ahead of the ban, thereby circumventing the effort to prevent rabies control efforts.¹³ 

Overall, this recent temporary CDC policy shift has illuminated the large number of organizations expending incredible resources to import stray dogs from abroad while American strays are euthanized daily. Shouldn’t available resources be focused on avoiding euthanasia of as many dogs as possible in the US before looking for additional dogs abroad? Especially if those imported dogs are potential disease vectors for diseases currently absent from the US?

In other words, if the US is battling overpopulation, why are additional dogs being imported by the millions each year? I encourage all veterinarians to make an effort to remain aware of these activities in the pet industry as well as encourage clients to purchase dogs that have empty passports. +

References

1. Notice of Temporary Suspension of Dogs Entering the United States. (2021, June, 14). CDC. https://www.cdc.gov/importation/bringing-an-animal-into-the-united-states/high-risk-dog-ban-frn.html 
2. US Declared Canine-Rabies Free. (2007, Sept, 7). CDC. https://www.cdc.gov/media/pressrel/2007/r070907.htm
3. Rabies. OIE. https://www.oie.int/en/disease/rabies/
4. Cost of Rabies Prevention. (2019, June, 11). CDC. https://www.cdc.gov/rabies/location/usa/cost.html
5. Dog Adopted By Chesco Family Had Dangerous Variant Of Rabies. (2021, June, 21). Patch. https://patch.com/pennsylvania/philadelphia/rabid-dog-azerbaijan-adopted-chester-county-family-cdc
6. Report on the Importation of Live Dogs into the United States. (2019, June, 25). AKC GR. https://cqrcengage.com/akc/file/ZSOYKBw3C5F/USDA_DogImportReport6_25_2019.pdf
7. Pet Statistics. (2015-2018). ASPCA. https://www.aspca.org/helping-people-pets/shelter-intake-and-surrender/pet-statistics
8. China Rescue Dogs. https://chinarescuedogs.org/about/# 
9. Moore County, NC Sheriff’s Office. https://www.moorecountync.gov/sheriff/animal-services 
10. Public Animal Shelter Report. (2017). North Carolina Department of Agriculture & Consumer Services. http://www.ncagr.gov/vet/aws/Fix/documents/2017PublicShelterReport.pdf 
11. Moore County, North Carolina Census. (2019, July, 1). United States Census Bureau. https://www.census.gov/quickfacts/fact/table/moorecountynorthcarolina/PST045219
12. High-Risk Countries for Dog Rabies. (2021, July, 14). CDC. https://www.cdc.gov/importation/bringing-an-animal-into-the-united-states/high-risk.html
13. US Suspends Dog Importation From 100-Plus Countries. (2021, July, 28). AMVA. https://www.avma.org/javma-news/2021-08-15/us-suspends-dog-importation-100-plus-countries 

The post Exploring the Dog Importation Ban (And the Reintroduction of Rabies) appeared first on PetVet Magazine.

In the age of warp-speed vaccine development (and manufacture and distribution), one wonders if other components of the healthcare system are progressing as quickly.  

Despite the truly awe-inspiring response from the health sciences in the face of SARS-CoV-2, the testing available proved less than ideal.  In fact, depending on which test was employed and the community prevalence, the results were often equivocal at best—even in the face of fairly sophisticated interpretation.  

Have clinical diagnostics kept pace with other areas of healthcare?  And how about veterinary medical care?  What is the current state of veterinary diagnostics for infectious diseases?  And, furthermore, what is the prognosis for diagnostics in the veterinary practice?

Diagnostic tests to determine health—or causes for the lack thereof—are not new. Diagnostic testing by physicians and veterinarians alike was not always the sophisticated practice of today.  

Prior to 400 BC, the oldest known test on bodily fluids was pretty straight forward. The patient’s urine was poured on the ground, and if the urine drew insects, then the patient was diagnosed with boils. Progress was made around 300 BC when Hippocrates performed a full diagnostic work-up by tasting the urine, listening to the lungs, observing skin color and other outward appearances. Bubbles on the surface of urine was readily tied to kidney disease, and chronic illness and hematuria was first documented as indicative of kidney failure circa 50 AD.  

In early times, urine was certainly the key to a diagnosis; so much so that failure to examine the patient’s urine allowed for a public beating of a physician, according to the Jerusalem code of 1090. While medical advancement suffered from a severe paralysis for centuries due to the hubris of Galen, by the time the 1600’s and 1700’s rolled around, health experts had “graduated” to assessing a patient’s urine…still!

Then, in the 1800’s, came the “Golden Age” wherein the shape of a patient’s skull could predict mental health and magnets were used to treat all manners of illness.  At least improvements in hygiene led to dramatic increase in survival rates overall.  Indeed, the late 1800’s produced Koch’s postulates and an epiphany regarding infectious diseases.  The concept of producing a pure culture of the disease-causing pathogen is still prevalent today.  

While we no longer rely on horses, wagons or even steam engines for transportation, we still refer to culture as a diagnostic gold standard for many infectious agents.  And while candles and lanterns are now reserved for austere and temporary events, culture remains a routine diagnostic method for many clinical conditions.  

What?!  Why?!  Why has clinical identification of a pathologic agent not kept pace with other facets of society and medicine? 

 Oh, but it has!  

In the early 1990’s, the world at-large was introduced to a cutting-edge laboratory process called polymerase chain reaction (PCR) via the US judicial system.  Thirty years later, even PCR has evolved and advanced.  But what bearing might any of this have on veterinary practice?  

While culture and sensitivity remain readily available, quantitative PCR (qPCR) has now become available to veterinary practitioners, a mere five to six years after appearing in human medicine.  While qPCR is certainly more sophisticated than a culture, is qPCR advantageous?  Less prone to error?  More sensitive and specific?  The short answer is “yes” to all of these.  

Consider that culture of a pathogen (bacterial, fungal or viral), at its most basic, provides the most welcoming environment and watching for the pathogen to appear.  Any number of imperceptible errors can impact the results of a culture; a small temperature excursion, incorrect nutrients provided, incorrect nutrient ratio or a random contaminant that may simply outpace the growth of the actual disease-causing organism. Quantitative PCR amplifies any known pathogen present in a sample and does so in such a way as to provide relative population comparison.  Thus, if a normal component of an animal’s microbiome is present in extreme numbers so as to produce pathology, that circumstance is reflected in qPCR while such growth might be routinely dismissed on interpretation of sample culture.  Therefore, the huge gap in traditional PCR appears to be bridged as qPCR can determine whether the organism detected is viable.  

Accurate assessment of the pathogen in question is not the only factor in effective treatment and diagnostics.  In an effort to avoid a “post-antibiotic” era, veterinary medicine must begin to acknowledge the value of more routine sensitivity evaluation prior to administration.  If qPCR is the cutting-edge for pathogen determination, then how is antibiotic resistance to be determined without growing a culture?  

Enter the era of PCR-determined antibiotic resistance. The ability of a pathogen to resist antibiotics is based on possession of genetic codes.  PCR technology can be used to determine whether or not a microbe population has the capability to express resistance.  It is true that just because the gene for resistance is present, the microbe is not necessarily resistant.  However, if resistance is a possibility, the engaged practitioner simply chooses an antibiotic where resistance is not known to be likely.  

While the practice of veterinary medicine remains a practice, in a world of warp-speed vaccine development and administration, it seems that clinical diagnostics for infectious diseases are poised to exceed impulse power. The next big step since the introduction of antibiotics seems to have arrived.  

With the introduction of molecular determination of pathogens combined with molecular determination of antibiotic sensitivity into the arsenal of the general practitioner, veterinary medicine is ready to truly enter the war on antimicrobial resistance.  This veterinarian’s prognosis for diagnostics in practice is positive! +

The post Diagnosis of the Diagnostics in Veterinary Medicine appeared first on PetVet Magazine.

But, no matter how quickly developed, no vaccine is effective until administered to the target population. So, how does that even happen when the country’s (and the world’s) population seems to have grown at the same warp speed? Let’s start with a bit of historical perspective.

Vaccination, variolation or immunization are much older practices than one might think. Records indicate that crude efforts towards protection through exposure were used as early as 1000 A.D. in Asia. However, most experts seem to agree that by the mid-1500’s, efforts to inoculate against smallpox infection were wide-spread in China and India. In the late 1600’s, insufflation was the common method of inoculation. Dry scabs might be ground into a powder and then puffed up a child’s nose, or the dry scabs might be soaked in water prior to being placed in the nose. Still, another common method was to take fluid from a pustule, place it on a cotton plug and then put the plug up the nose of the child. 

By the 1700’s, trade routes had spread the practice to most of Europe and likely also allowed for the further variations in administration. The Chinese even described a method that amounted to a crude attenuated vaccine by carrying the contents of a pustule (pocky matter) at body temperature for a month, or exposing it to steam and herbs prior to placing on cotton and then into the nose. It’s likely that this handling allowed for inactivation of some viral particles and decreased the overall viral load, resulting in a very crude attempt at a modified-live vaccine. 

Fast forward to 2020, and smallpox is no longer the major focus of immunization efforts. Today’s medical sciences use a plethora of different approaches to safely stimulate immunity against a number of potentially life-threatening pathogens. Each vaccine type may use a novel platform or delivery system, target a different component of the viral molecule or seek to stimulate a specific portion of the host immune system. While each of these approaches has a unique set of advantages and disadvantages (see above table), all share a common potential point of failure. To be effective, vaccines must be administered on an individual level—no vaccine is effective if it remains in the vial! 

The portion of the population that must be immune to confer “herd” immunity varies from disease to disease and is related to how contagious the disease is from person to person. For example, an estimated 94% of the susceptible population must be immune to measles to disrupt transmission. For SARS-CoV-2, current estimates are that 70% of the population must be immune to interrupt transmission. In 2020, the estimated U.S. population is ~330 million. Thus, 231 million (or more) Americans would need immunity conferred by either natural disease recovery or vaccine to effectively interrupt the transmission of SARS-CoV-2. Current estimates are that ~5 million Americans have tested positive thus far; that’s a very long way from 231 million.

So, how do we administer roughly 200 million vaccinations to individuals all across the country? How long will it take? Some estimate that natural immunity may only last months rather than years. So does a vaccination campaign then race against the waning immunity of those recovering from natural infection? Well, we may not know the answer to how long natural immunity lasts, but we do know how to administer mass vaccination campaigns. In fact, much of the infrastructure for such efforts exists in most cities in the U.S. since President Kennedy signed the Vaccination Assistance Act into law in 1962, which provides for the mass vaccination of the population with a focus on pre-school-aged children. Additionally, the act allowed federal funds to go to state and local authorities to support vaccination of the entire population. 

The anthrax attacks of 2001 required life-saving medical counter-measures (MCM) to be distributed and administered to nearly 2,000 people in a very short time period. The survival rate for inhalation of anthrax declines precipitously if MCM are not administered within 48 hours of exposure. 

In 2004, the Centers for Disease Control and Prevention (CDC) established the Cities Readiness Initiative (CRI). The CRI program is a federally-funded program to enhance local preparedness for biological incidents. The CRI program targets a system of Metropolitan Statistical Areas (MSAs). Each state has at least one MSA and the total population of all the MSAs together is about 60% of the U.S. population. 

The CRI programs are responsible for cultivating relationships with large (and not so large) employers in their local areas. Both government and private employers are eligible to participate in efforts to provide lifesaving MCMs to their employees (and their families) by order that the employer serve as a force multiplier for distribution to meet the CRI target distribution window of 48 hours. Jurisdictions are required to maintain written plans for effective distribution schemes down to the smallest of details. Granular information such as driving routes to likely distribution points in a community is included. CRI communities are also required to exercise all components of plans routinely with analysis and corrective actions included in After Action Reports (AAR). Since the CDC funds CRI preparedness efforts, naturally, the local CRI programs are reviewed by CDC personnel regularly as well.

CRI sounds like a great idea; execution seems assured and wide-spread distribution of MCM appears well in-hand. But, anthrax-related medications such as ciprofloxacin do not require refrigeration nor injection. So, how does this change things? The good news is that vaccines requiring refrigeration are not a novel invention and such items are distributed nationwide on the daily. Federally funded CRI programs are required to provide logistics for temperature-controlled distribution plans, as well as inert products not requiring climate control. 

With climate control and distribution handled, we should turn our focus to administration of a vaccine in such a circumstance. If the hotly anticipated SARS-CoV-2 vaccine is an oral formulation, then the celebration can begin! By and large, Americans, and humans in general, are much more likely to accept a medication that is orally administered than one that is injected with that super scary object—a needle! However, it is much more likely that the vaccine will require injection instead of a simple gulp. 

Many healthcare professionals are discussing vaccines and vaccine development on webinars these days, and when the nearly inevitable question arises of who will administer all these vaccinations, given the current burden on the healthcare system, these otherwise well-informed professionals are at a loss. Many folks are wholly unaware of the legal framework in place in the U.S. for just these events. In fact, the existing framework allows for a broad swath of trained healthcare professionals to join the vaccine administration team, including, but not limited to, pharmacists, nurses, dentists and veterinarians. Additionally, all of those appropriately integrated into the public health response and under the direction of the local public health officer are typically immune from liability while conducting approved activities such as vaccine administration pursuant to a blanket prescription order. The only actions not covered by this umbrella of immunity are those committed outside of assigned tasks or those committed with willful misconduct (Federal Public Readiness and Emergency Preparedness Act (PREP Act)).  

I strongly recommend that veterinarians join their local Medical Reserve Corps (MRC) and get engaged, if not involved, in local public health efforts, even outside of a pandemic. Surely during a pandemic veterinary professionals and support staff will find the MRC an incredible outlet for community engagement and soul-satisfaction through community volunteerism. The beauty of integration with the MRC is the “cloak” of protection provided by the program’s practice of full coverage for members while actively employed in assigned tasks.

To the larger issue that will no doubt dominate media coverage and supper table discussions alike, I have no solution. That issue is public acceptance and recognition of the newly-minted vaccine as safe, efficacious and necessary. Accurate information is the only antidote to fear, and if the media coverage of this pandemic to date is any indication, accuracy is not likely to be wide-spread. So, the vaccine may sit idly in a refrigerated container at a point-of-dispensing (POD) staffed by veterinarians and medical professionals alike with no one in which to administer the potentially life-saving MCM. 

What to do to resolve this? Veterinarians can begin by making herculean efforts to remain abreast of any developments down the path to a safe and efficacious vaccine. We can also share this information with our colleagues, staff members, clients and anyone who is interested. Tell them it could be worse…at least we are not proposing to stuff a puss-soaked cotton ball up their nose and ask them to leave it there for a few days. +

Resources

1. Boylston A. The origins of inoculation. J R Soc Med. 2012;105(7):309-313. doi:10.1258/jrsm.2012.12k044
2. https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/herd-immunity-and-coronavirus/art-20486808
3. https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
4. https://www.census.gov/popclock/
5. https://www.rand.org/content/dam/rand/pubs/technical_reports/2009/RAND_TR640.pdf
6. https://www.cdc.gov/cpr/readiness/mcm/cri.html
7. Centers for Disease Control and Prevention. Vaccine-Preventable Diseases, Immunizations, and MMWR — 1961–2011. MMWR 2011;60(Suppl):49-57. 
8. https://www.phe.gov/Preparedness/legal/prepact/Pages/default.aspx

The post Vaccination in the Time of COVID-19 and Before appeared first on PetVet Magazine.

When I was growing up, my life was dominated by a just a handful of facts that I knew to be universally true, including: Bubbalicious watermelon was the best ever, all the cool kids watched MTV and the vet was interesting.  “The vet”—as though there was only one, like Cher, Madonna or “the doctor.”

What makes this odd is that I actually knew several veterinarians for most of my life. I grew up watching Dr. Fletcher develop incredible new surgical procedures for birds on our back patio. But he wasn’t, “the vet.” No, “the vet,” who I eventually knew as Dr. Goldman, was the guy with a clinic in town who would put my favorite barn cats on antibiotics when they got too beat up. He was an affable and intelligent guy. I loved staring endlessly at his posters of dog and cat breeds and dreaming of what type of kitten or puppy I would get first. 

Fast forward, and Bubbalicious watermelon is still the best ever, the cool kids are checking out Snapchat and “the vet” is no longer just “the vet.” Veterinary medicine has become incredibly sophisticated in practice, while at the same time, evolving into an incredibly specialized clinical art. While this is interesting, what does it mean to the average pet owner? Not much! Many, if not most, pet owners and animal care professionals have no real understanding of the complexity of veterinary medicine today. Frankly, many veterinarians struggle to understand the multitude of specialists among their colleagues. 

Beyond the Doctor of Veterinary Medicine (DVM) that veterinarians receive (except in Pennsylvania where a VMD is conferred), what is all that alphabet soup and does it really matter to the care of an animal?

I am sure many of you have noticed the slow evaporation of the general practitioner from the human health landscape. I do not know anyone who has a true general practitioner anymore, do you? Sure, people have doctors, but they have an Ob/Gyn, a dermatologist, a cardiologist or an internist that handles primary complaints, and acute illnesses may be handled by a walk-in urgent care site. I loathe this current system! I love a good GP. But, I am not so foolish as to fail to recognize the value of specialists when needed. My point is that the human healthcare ecosystem may be suffering from an imbalance of providers—too many specialists and very few general practitioners. 

Thank goodness veterinary medicine has not yet lost the GP. “The vet” is incredibly important in the life and relationship of a pet and their owner. A DVM degree indicates a broad swath of knowledge appropriate for seeing primary presentations of animals from all environments. Indeed, a GP veterinarian is well-versed in internal medicine, surgery, preventive medicine, parasitology, pediatrics and more. However, for some cases, owners may desire a more focused approach for their pet. At that time, it is appropriate for “the vet” to make a referral to a specialist. While the referral is not obligatory in the majority of locations, it certainly can enhance the performance of the total care team in most circumstances, and is certainly the structure for care that I recommend, if feasible. 

How many specialties and specialists are there in veterinary medicine? 

How are the specialties determined and how does “the vet” earn those extra letters?

In the early 1950’s, two specialties were proposed in the AVMA: the American College of Veterinary Pathology and the American Board of Veterinary Public Health. Since that time, many more have been proposed and established. Currently, the AVMA recognizes 22 different specialty organizations, overseeing 41 different specialties with roughly 10% of veterinarians holding board-certification in at least one specialty, and fewer still being board-certified in two or more specialties. 

Does the existence of specialties mean that “the vet” is unable or unqualified to perform surgeries, read x-rays, perform anesthesia or manage medical cases themselves? Is a referral to a specialist required? Of course not! GP veterinarians are more than capable of practicing the full scope of veterinary medicine and providing incredible medical care to patients. The specialist is simply another tool that the GP and animal owners can utilize to augment the animal care team in particularly challenging cases, or when an animal owner requests advanced care. Essentially, most specialties that exist in human medicine are available in veterinary medicine, plus a few extras. 

Board-certified specialists are called “diplomates” of their board and their status is expressed as either Dipl. or with a “D” followed by the specialty abbreviation. Some examples include:

• Dipl. ACVS or DACVS: Diplomates of the American College of Veterinary Surgeons (ACVS) have typically completed at least a one-year internship and a three-year residency before completing a multi-day board certification exam. Diplomates may be focused on either small animal (SA) or large animal (LA) surgery and the focus is typically expressed as: DACVS (SA) or DACVS (LA).

• Dipl. ACVPM or DACVPM: Diplomates of the American College of Veterinary Prevention (ACVPM) are largely regarded as specialists in infectious disease, epidemiology, food safety, biostatistics, toxins, disaster response and public communication. The ACVPM originated as the American Board of Veterinary Public Health in 1950 and was renamed multiple times in its history, finally settling on ACVPM in 1973. The evolution explains why many refer to the ACVPM as the “public health specialists” and why many consider the Diplomates specialists in One Health. Diplomates must pass a two-day board examination, as well as certify a number of years engaged in public health management at a high level.

• Dipl. ACVIM or DACVIM: Diplomates of the American College of Veterinary Internal Medicine (ACVIM) are further sorted by cardiology, large animal internal medicine, neurology, oncology and small animal internal medicine, which is sometimes indicated in parentheses following the ACVIM abbreviation. Diplomates have completed at least a one-year internship, or equivalent broad-based clinical practice experience, followed by a three-year residency before passing the multi-day board certification exam.

Some veterinarians may list other designations after their DVM, including Certified Veterinary Journalist (CVJ), Certified Veterinary Practice Manager (CVPM), Certified Acupuncturist, Veterinary Orthopedic Manipulation (VOM) and a myriad of others. However, most of these are not recognized veterinary medical specialties and pet owners should be aware that some merely require an annual membership payment. 

For a complete list of recognized veterinary specialties and more information on the rigorous programs to obtain board certification, check out the American Board of Veterinary Specialties (https://www.avma.org/education/veterinary-specialties). 

After all this, what is universal—no matter the string of letters after the name or how the letters are obtained—is that veterinarians not only care for animals, but seek to protect that most incredible bond between humans and animals by assuring that both can live together without presenting a threat to the health of each other. Care and compassion requires no additional training, degree or letters to be visible to animals and to their owners. +

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