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UPDATESINCANINEINFLUENZAVIRUS:MANAGEMENT,DIAGNOSIS,

TREATMENT,PREVENTIONANDVACCINATION

Dr.JasonStull,VMD,MPVM,PhD,DiplomateACVPMDr.JeniferChatfield,DVM,DiplomateACZM

Dr.JarodHansonDVM,DACVPMDr.JustineLee,DVM,DACVECC,DABT

Dr.GarretPachtinger,DACVECC

THANKYOU!

GarretPachtinger,VMD,DACVECC

COO,VETgirl

Introduction

JustineA.Lee,DVM,

DACVECC,DABTCEO,VETgirl

Introduction

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Dr.JeniferChatfield,DVM,DiplomateACZM

Dr.JasonStull,VMD,MPVM,PhD,DiplomateACVPM)

Dr.JarodHansonDVM,DACVPM UnderstandingCanine

InfluenzaandDiagnosticsJarodHanson,DVM,PhD,DACVPM

CanineInfluenza:InfluenzaAinCompanionAnimalSpecies

• Canineinfluenzavirus• Family:Orthomyxoviridae• Negativesense,single-strandedRNAvirus

• Diameter:80-120nm(0.08-0.12um)

• Speciesaffected:dogs,cats,ferrets,guineapigs

• Theinfluenzatriad:humans/birds/swine

• Themammalian/avianmixingpot

CurrentCanineInfluenzaSubtypes

• Hemagglutinin:H• 1-18• 17/18seenonlyinbats

• Neuraminidase:N• 1-11• 10/11seenonlyinbats

H3N8andH3N2aretheprimarysubtypesaffectingdogs• Otherstrains:H1N1,H3N1,H3N2(cats),H5N1,H5N2,H5N6,H6N1,H7N2(cats),H9N2,likelyH7N9

• huH1N1indogs/catsduringthe2009huH1N1humanpandemic

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InfluenzainDogsandCats:2005-Present

• 438totalisolates• 423fromdogs• 15fromcats

Lackofsurveillance:• Influenzasurveillanceincompanionanimalsisabysmalcomparedtohumans,pigs,orpoultry

Howdidwegofromnofluindogstothis?

• ViralMutations• Shift

• MajorchangesinHorNtypes:leadstonewviralphenotypeunrecognizedbytheimmunesystem

• CurrentcanineH3N2viruscontainsaviansegments• Requires2virusestoinfectthesamepatient

• Drift• ViralRNApolymeraselacksaproofreadingmechanism

• Higherrorrateleadsto“new”virusesduringeveryinfection

• Sufficientdriftleadsto:• Renewedsusceptibility• Crossovertonewspecies

• Globalpopulationmovements

InfluenzaStrains:aHistoricalSelection

LPAIH7N2:catsandaveterinarianinNY

CurrentH3N2caninestrains

Otheruniqueflustrainsincompanionspecies

CanineH3N8:it’sstillcirculating

2historicH3N8equinesubtypes

ACloserLookatH3N2EvolutioninDogs/Cats

OriginsinKoreaandChina2005-2007

8yearsofviralevolutionandadaptation

2015outbreakstrainfromKorea

OtherH3N2,includinghumanseasonalstrains

SeparatelineagedevelopinginChina

DivergenceOccurredQuicklyintheUS

SoutheastUS

CentralUS

InitialKoreanstrain

H3N2OriginandEndemicity

• HowdidaKoreanvirusgettotheUS?• Importedshelterdogs• Importedpets

• EpidemicorEndemic?• RepeatedreintroductionsofthevirusfromAsia• Environmental:virusdessicates anddiesoutsidehost• Animalreservoir:feraldogs/cats• Endemic:circulatinginthecanine+/- felinepopulation

• Dogshows• Shelters• Doggiedaycares• Groomingfacilities

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ParadoxicalReverseSeasonalPattern

• Humanseasonalflu:fallintolatespring• Prolongedvirussurvivaltime(cold/lesssunlight)• Peoplespendmoretimeindoorsincloseproximity

• Canine:springintofall• Moretimespentincaninesocialsettings:dogparks• Moretravelwithpets:moreopportunitytotransportvirus• Summer:boardingseason• March-July:>80%ofH3N2canineflureports(datafromProMED-mail)in2016and2017

Thevirusisspreadingwhenenvironmentalconditionsareleastfavorable…

CanineInfluenzaTransmission• Secretions

• DirectContact• Liquids/Droplets(>5umdiameter)

• Essentiallydirectcontact(5feet)• Eyes,upperrespiratorytract

• Aerosols(<5umdiameter,butgreaterviruscontent)• 20feetinanairspace• Lowerrespiratorytract

• MechanicalVentilation• Candisseminatevirusoverlongdistances• HEPAorotherhighefficiencyfilters• HouseholdfilterswithMPR>1900:0.3um-1umparticles

• Fomites• Contaminatedsurfaces,gloves,stethoscopes,laryngoscopes,etc.

CanineInfluenzaDiagnostics

• Acutephase• Serology:the“PRE”sample

• Requires“POST”sampleseveralweekslater• Easyandpartofroutineworkup• Maynotbeusefulifvirusdoesn’tmatchserologyantibodies• Initialsampleshouldhaveno/fewantibodiesinacutepresentation

• Nasal,Oropharyngeal,and/orConjunctivalSwabs• Nasalswabsare2-3timesmorelikelytofindapositivethanOPswabs

• Conjunctivalswabsarehighlydependentontheviruspresent• Tissuesamples:freshlungtissueorswabs

• Chronicphase• Serology:the“POST”sample

AppropriateSwabs

• Polyester/Dacron• Flockswabs• Bacterialcultureswabs• Plastichandles

• Avoid:• Woodenhandles• Cottonswabs(limitedtonovirusrecovery)

FollowtheDiagnosticLab’sRecommendations,butBewareoftheConsequences…

Dessication killsthevirus!!!

DiagnosticLabsandTesting

• Wheretosend:multiplecommercialandacademiclabswithmanytestoptions

• Whattoorder:• Ataminimum:

• H3N8andH3N2PCR• SomelabswillrunamatrixPCRfirst(screeningtest)thensubtypethepositives• Labsrequestingdryswabsaretypicallynotdoingvirusisolation

• Ideally:• Arespiratorypanel:suspectedfluisoftensomethingelse• MatrixPCR,ormultiplexPCRforH3N8,H3N2,H7N2,H1N1+/- H5N1• VirusisolationonanymatrixPCRpositives(mostimportantonPCR-untypable strains)

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EnhancingVirusRecoveryandSurvival

• Don’tusecottonswabs• Don’tpre-moistentheswabs• Don’tfreezethesample,evenoveralongweekend• Moistentheswabwithsalineorviraltransportmedia

• Virusonproperlymoistenedandrefrigeratedswabscansurviveformorethanaweek

• Ensuretubesdonotleakordessicate duringshipment(parafilmortapethecaptothetube)

• Shipsamplesovernightonicepacks

Bestpracticesforsanitationandisolationandlessonslearnedfromprevious

outbreaksJeniferChatfield,DVM,DACZM

Whatweknow…CIVoutbreakstypicallyresultfrom:

• Directdog-to-dogcontact• Fomiteandaerosoltransmissioninstressfulenvironmentswithhighpopulationdensitiessuchas:

• Boarding• Daycare• Grooming• Veterinarymedicalfacilities• Animalshelters• Petstores• Caninesportsorothercompetitions

Isolation?Quarantine?

• Isolation =usedtoseparate ill animalswhohaveacommunicablediseasefromhealthyanimals

• Quarantine =usedtoseparateandrestrictthemovementofwell animalswhomayhavebeenexposedtoacommunicablediseasetoseeiftheybecomeill.Theseanimalsmayhavebeenexposedtoadisease,ortheymayhavethediseasebutdonotshowsigns

Goalofboth=stopdiseasetransmission!

IsisolationofCIVpatientsREALLY necessary?

• Existingpopulationislargelyimmunologicallynaive

• Morbidityrateassociatedwithcanineinfluenzaisestimatedat80%

• CIVH3N2ismuchmorecontagious(orreadilytransmissible)thanH3N8

• IsitCIV?OrCIV+bacterialinfection?OranewCIVstrain?

Howdoweisolate?

• Exteriorentrydirectlyintorarelyusedexamroom,ifpossible

• Separateair-handlingfortreatmentarea/cagearea

• Dedicated/limitedpersonnel• Removewaste(excrement,exudate,etc.)assoonaspossiblefromcage

• NOcontactwithotheranimals

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ProlongedintermittentvirussheddingduringanoutbreakofcanineinfluenzaAH3N2virusinfectionindogsinthreeChicagoareashelters:16cases(MarchtoMay2015)

Sandra Newbury,Jennifer Godhardt-Cooper,KeithP. Poulsen,Francine Cigel, MS; Laura Balanoff, DVM; Kathy Toohey-Kurth;JAVMA.May1,2016,Vol.248,No.9,Pages1022-1026

• EstimateappropriateisolationperiodfordogsinfectedwithCIVH3N2virusonthebasisofthedurationofvirusshedding.

• 16dogs,from3Chicagoareashelters,naturallyinfectedwithCIVH3N2virus.

• VirusesfromeachdogwereidentifiedasCIVH3N2virusonthebasisofDNAsequencing.TheintervalbetweenfirstandlastpositiverRT-PCRassayresultsrangedfrom13to24days

• DogsinfectedwithH3N2virusshouldbeisolatedforaperiodof≥21daysfollowingonsetofillness.

• Evenwhenresolutionofclinicalsignsoccurssoonerthan21days,sheddingofH3N2virusmaypersist.

Afterthesheltersextendedtheirisolationprotocolsto21days,newinfectionsdecreasedsubstantially.

Meanwhile,backintheexamroom…

…disinfectionfollowingsuspected CIVcase!

First,removeanyorganicdebris(clean)

• Cannotdisinfectorganicdebris!

• Cleaningremovesgerms,dirt,andotherdebrisfromsurfaces

Disinfecthardsurfaces

• Disinfectingkillsgermsonsurfaces• Useproductsaccordingtolabelinstructions– includingallowingforcontacttime

• Softitems(towels,blankets,etc.)canbewashedasroutine(recommendhotwater,detergent,andbleach)

• Itemsthatcannotbewashedshouldbediscardedappropriately

Disinfectionfollowingsuspected CIVcase

• Quaternaryammoniumcompounds(i.e.benzalkonium chloride)• Aldehydes• Potassiumperoxymonosulfate• Phenols• Bleach(1:30) solutions

Besuretoallowsufficientcontacttime!

WashinghandsisCRITICAL

• Handwashingreducestransmissionofrespiratoryillness• Rabie T,CurtisV.Handwashingandriskofrespiratoryinfections:aquantitativesystematicreview.TropicalMedicineandInternationalHealth2006;11(3):258-267.

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Staff

• Limitedpersonnelincontactwithaffecteddogs• Personnelcontactpatientsinthisorder:

1. Healthy2. Young3. Oldest4. Sickest

• Ifpossible,onlystaffwithnodogsathomehandlepotentialCIVcases

• Considerchangingscrubtops,footbaths,etc.

Educatestaffandclientsonproperinfectioncontrol

DiseasePreventionwithDogsinGroupSettings

JasonStull,VMD,MPVM,PhD,DACVPM

TheCanineGroupSetting

• Cometogether• Sharedenvironment• Temporary• Manydogs• Local/International

• Shows• Sportingevents• Dogparks• Trainingclasses• Dogdaycare• Boarding

Diseaseoutbreaks?Localcommunity,widespread?

MultipleFactorsInfluenceInfectionRisks

Environmental disinfection

Hand hygieneContact precautions

Surveillance Antimicrobial Use

Event/Facility

Infections

AnimalProcedures

Outbreaks &Into

Community

Education & Awareness

Vaccination

RecommendationAreas

1. General:nosickdogs2. Vaccination:core+lifestyle3. InsectandWildlifeControl4. Vectorandvector-bornedisease5. Entericdisease6. Environmentaldisinfection/hygiene7. Facilitydesignandtrafficcontrol8. Diseaserecognition/response:exposeddogs

Keyforcaninefluprevention

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Vaccination

•Coreforgroupsettings• Distemper• Adenovirus• Parvovirus• Rabies• Bordetella• Parainfluenza

•Timeforimmunityandboosters

Non-CoreVaccination

• Basedonrisk• CaninefluH3N8andH3N2

• 2doses,2-4weeksapart• Annualbooster

• Lyme• Leptospirosis

EnvironmentalDisinfection&Hygiene

•Staff&ownersperformhandhygiene• Entryandexittoevent• Betweendogcontacts(groups)

EnvironmentalDisinfection&Hygiene

•Reducemulti-dogcontacttoitems• Bring(anduse)ownitems• Singledoguseprovidedbysetting

FacilityDesignandTrafficControl

•Unnecessarydog-dogandperson-dogcontact

•Duringanoutbreakavoidhighlypopulateddogareas

PetOwnerCommunication

• Asktherightquestions• Helptounderstandandalterrisk• Open,two-wayexchangeofinformationandopinion• Empowertomake informeddecisions

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AvailableResources

http://go.osu.edu/IDk9risk

RiskCalculator• Audience:Public• 5-10min• Immediatepersonalizedfeedbackonriskreduction

http://go.osu.edu/IDk9risk

Checklist

http://go.osu.edu/IDk9risk

Clinicalsignsandtransmission

JustineLee,DVM,DACVECC,DABT

ClinicalsignsofCIV

• Coughing(95%)• Lethargy/weak(70%)• Inappetance(63%)• Fever(58%)• Nasal/oculardischarge(49%)• GIsigns(27%)• Pneumonia(20%)

• Tachypnea(atrest)• Tachycardia• Coupageà cough• Constantpanting• Dyspnea• Exerciseintolerance• Cyanosis• Collapse

Physicalexamination

•Coughing•Lethargic•Nasal/oculardischarge•Dehydration•Fever(T>103°F/39.4°C)•Abnormalauscultation

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CanineInfluenza• Mildform:

• Cough– canbeverypersistent,30-60days• Fever• Nasaldischarge

• Severeform:• Pneumoniawithhypoxiain~10%ofdogs• Mortalityrateupto8%

• Secondarybacterialinfectionsarecommonandworsenclinicalsigns• Nasal:Staphs andStreps• Pulmonary:Bordetella andMycoplasma• Strepzooepidemicus (hemorrhagicpneumonia)

TreatmentJustineLee,DVM,DACVECC,DABT

Primarysurvey

• Immediateassessment

• StabilizationoftheABCDs!• Airway• Breathing• Circulation• Dysfunction

•Cyanotic=paO2 <40mmHg• Abouttoarrest– treatimmediately!

•O2 therapy!

GoalsofTreatment

•Hydration•Oxygenation•Antibiotictherapy•Nebulizationandcoupage• Supportivecare•Anti-emetictherapy

Treatmentprotocols:IVfluidtherapy

• Ensurehydration• Preventdehydrationofairwaysecretionswhichworsenabilitytobeexpectorate

• Replacehydrationoverseveralhours• Crystalloid

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OxygenTherapy

• Oxygen• Pulseox<92%?NEEDSO2!

• EstablishAirway

• IVaccess

Antibiotictherapy

•Viralinfectionbutconcernaboutsecondaryseptichemorrhagicsyndromeinseverecases

•Mixedbacterialflora• Gram+/-

•Combinationbroad-spectrumantibiotictherapy

•Routeofdelivery• IVorIM• Ifstable,switchtooralafterinitialIV/IMdose

Antibiotictherapy• Broadspectrumantibioticsifsecondarybacterialinfectionsuspected• Doxycycline• Amoxicillin/clavulonic acid• Enrofloxacin +amoxicillin/clavulonic acid• Enrofloxacin +cefazolinorampicillin• Amikacininhydratedpatientsonly

Nebulizationandcoupage• Goals:

• Hydrate• Loosen/expectoratesecretions

• Promoteexpectoration

• Coupageq.4-6hours

Miscellaneoustreatment•Coolingmeasures?

• IfveryelevatedTà DIC• StopcoolingatT>103°F/39.4°C

•Analgesics• Ifpainful,treat.• Beawareofrespiratorydepressionandcoughsuppressionw/opioids

•One-time,anti-inflammatorydoseofDexSP?• Viral!

Treatment

• Tamiflu- notrecommended• Antibiotics- secondaryinfections

•ShouldbebasedonC&S• B.bronchiseptica

• Doxycycline,TMS• AlwaysresistanttoCephalexin

• Strep.Zooepidemicusorothersecondarybacterialinfections• Clavamox,cephalosporins,fluoroquinolones

• Onlyusesteroidsandanti-tussivesifabsolutelynecessary• Rest• +/- nebulizersandcoupage

•Mayincludeaerosolizedantibiotics

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Furtherdiagnostics

• Physicalexamination(PE)• Chestradiographs• Pulseoximeter• Arterialbloodgas

Summaryoftreatmentrecommendations

•Coughsuppressants onlyifbacterialpneumoniaisruledout.

• Immediateisolation

• Lowstressenvironment

Furtherdiagnostics

• Oralantibiotictherapyfor2-6weeks

• Recheckserialradiographs

• Continueantibiotics1-2weekspastresolutionofradiographicdisease

Appropriateclientcommunication

• Educateownersappropriately

• Discusspreventativecare• Nodoggydaycares• Minimizedogexposure• Vaccination?

• Recognizeandtreatappropriately

Sohowdoweprotectourcaninepatients?

ToolsforPreventionofCIRDcomplex:Vaccines

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Conclusion

• Rapidrecognition• Appropriatehistory(e.g.,travel,boarding)• Appropriateeducation• Re-evaluateyourboardingpolicy• Appropriatedisinfection• Minimizenose-to-nosecontactduringoutbreaks• Vaccinationwhenappropriate

Q&A

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