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The unnecessary death of the Ebola dog

Ebola virus hysteria is taking hold of the northern hemisphere. The latest victim was a cross-bred dog called Excalibur, who was euthanased by the Spanish authorities even though he showed no signs of being infected with the virus, and despite the fact that there is no evidence that dogs can transmit Ebola to humans. The twelve year old rescued dog had the misfortune to belong to a Spanish nurse who became the first person to become infected with Ebola in Europe after nursing a Spanish missionary priest who had been repatriated from Sierra Leone to Madrid for intensive treatment. The priest died of the virus on September 25th,, and the nurse is thought to have picked up the virus after touching her face with a contaminated glove as she removed her protective suit after finishing her shift. Excalibur was a much loved pet in perfect health, and after Madrid's regional government obtained a court order to euthanase him, the nurse's husband put out a call for his life to be saved. An online  petition rapidly gathered over 400000 signatures, and crowds of angry animal-loving protestors had to be restrained by police outside the apartment where the dog lived. Despite the protests, Excalibur was euthanased. The deed has been done. But was it really necessary? Did the animal present a risk, or was he just a scapegoat sacrificed to give the authorities a sense that they were doing something? There is scanty evidence to support killing a dog in a situation like this. Bats are thought to be the natural reservoir for the Ebola virus in central Africa, carrying the virus without showing signs of illness. Monkeys and apes become infected and fall seriously ill, like humans. But despite extensive research, there's been almost no evidence of other animals becoming infected or carrying the virus. There is one study that casts a cloud over the innocence of dogs: researchers investigating the 2001-2002 outbreak of Ebola in Gabon found low levels of antibodies in blood samples from dogs in areas where there had been cases of Ebola in humans and apes. This confirmed that the dogs had been infected with the virus, but it was impossible to know the source of their contact: from bats, apes, or from humans? It was also not possible to determine whether the dogs could have been infectious to humans at some point. In theory, the fact that they had been infected with the virus implies that at some point they may have shed the virus in their secretions, in the same way as infected humans pass on the infection. Some researchers believe that it would have been wiser to have kept Excalibur alive, not for sentimental reasons, but to learn more about the spread of the disease. If he had been kept in quarantine, serial blood samples could have been taken, monitoring his immune status. The question of whether or not dogs need to be included in Ebola virus control schemes could have been definitively answered in a safe environment. And if he had been clear of any sign of the virus after several months, he could have been released from quarantine to resume a normal happy doggy life. Sorry, Excalibur: the precautionary principle and the political need for action seized the initiative: we still don't know much about Ebola in dogs, and you'll never enjoy another happy walk with your owners.

Are vets more interested in the health of their patients or the money in their pockets?

I recently wrote a blog here titled "Debunking myths about “rip off" veterinary fees”, and since then, the subject of money has continued to be one of the banes of my life as a vet in practice. My aim in life is to do a job that I enjoy, and to be paid a reasonable salary: for most people, that just means that you go to work, do your stuff, and come home at the end of each day. For vets, it's different: every day, as part of our job, we need to ask people to give us money. Most of us would be delighted if this discomfitting task was taken away from us, but unfortunately, it's an unavoidable part of our job description. One recent case provided a good example of the type of daily dilemma that faces vets. An elderly terrier, Sam, had a small benign tumour on his flank. He was fourteen years of age, and his owner had been hoping that we might be able to leave the tumour alone: it'd be better to avoid a general anaesthetic unless it was absolutely necessary. When the tumour began to ooze blood, and Sam began to lick it a lot, we couldn't leave it any longer so he was booked in for surgery. When booking the operation, I mentioned to his owner that it would be wise to take the opportunity to clean up his teeth, which were caked in tartar. And I gave a detailed estimate of the expected costs. We took all the usual precautions to ensure Sam's safety. He had a detailed clinical examination and pre-anaesthetic blood tests to ensure that he had no underlying illnesses that could make an anaesthetic risky. An intravenous line was set up to give him continual fluids during the procedure and to give us instant access to a vein if any emergency treatment became necessary. And a vet nurse was designated to hold his paw and to monitor him for every second of his time under anaesthesia, from induction until he was sitting up at the end. Everything went well: the tumour shelled out quickly and easily, and a line of sutures closed the wound. I carried out a thorough descale and polish of his teeth, as planned. But it was then that the dilemma arose: beneath the tartar covering his teeth, it turned out that two of his molar teeth had large diseased areas. The gum margins had recessed, exposing large parts of the tooth roots. One of the teeth had serious infection, causing the tooth to be loose: it was easily removed. The other molar tooth was more complicated: one root was seriously diseased, but the other two roots were healthy. The tooth needed to be extracted, but it would be a tedious, time consuming surgical extraction, taking over half an hour, and requiring follow up x-rays to ensure that it had been done properly. This would involve an extra cost to the owner of well over £100. I had already given an estimate, and I didn't feel that I could go ahead with this without permission. While Sam was still anaesthetised, I asked a nurse to phone his owner to explain the situation. There was no answer on the home line, and the mobile number wasn't working. What should I do now? If I went ahead, I'd be carrying out unauthorised work on someone's pet. If there were any unexpected complications, the owner could hold me liable. And as for the extra cost? Could the owner justifiably refuse to pay? The safest legal approach would be to make a note of what needed to be done, and then to inform Sam's owner that he needed a follow up anaesthetic in a few weeks, during which we'd tackle his dental issues. But I knew that it would be far safer for Sam to have the entire procedure completed during this first anaesthetic, and I knew that his owner would be unlikely to agree to pay for a second anaesthetic on top of this first one. So Sam's dental issues would probably not be treated, and he would suffer as a consequence. I made an "on the hoof" decision to go ahead with the dental procedure. It took even longer than I had anticipated, and I had to take a series of x-rays rather than just one. By the end, I was happy that Sam had been given the best treatment, but I was nervous about the owner's response. Would she think that I had done this just as a way of extracting more money from her? What if she genuinely couldn't afford more than the estimate that I had given her? I felt so uncomfortable about the situation that I gave a significant discount on the extra work that I had done. Effectively, I ended up working my lunch hour for nothing because I felt so awkward about it. But what else could I have done? In the interest of the dog, I could not have left painful, diseased teeth untreated. What would pet owners feel if the vet presented them with a situation like this? Should you pay the full amount of justifiable extra work if it is unauthorised?  Do you trust your vet? Or do you feel that we are working more for our own interests than for the benefit of your pet?  

Sensationalist reporting of TB in cats is not helpful: does the media want a cat cull?

Let's start with the facts about the cats with TB, as reported in the Vet Record: perhaps surprisingly, these have not been published in full in any of the mass media outlets in the past two days: ++++++++++ BETWEEN December 2012 and March 2013, a veterinary practice in Newbury (west Berkshire) diagnosed nine cases of Mycobacterium bovis infection in domestic cats. In seven of those cases the diagnosis was confirmed by bacteriological culture. The nine affected cats belonged to different households and six of them resided within a 250 metre radius. The animals presented with mycobacterial disease of variable severity including anorexia, non-healing or discharging infected wounds, evidence of pneumonia and different degrees of lymphadenopathy. The latest information is that six of the cats have been euthanased or have died. The three surviving animals are undergoing treatment and are reported to be responding. At the time of writing, no new cases had been detected in local cats since March 2013. ++++++++++ The newspapers have missed this aspect of the story, and focussed entirely on the fact that the disease, for the first time, seems to have been passed on to two humans who had been in contact with one of the cats. The humans have responded well to treatment. Despite journalists' suggestions that the cats could have picked up TB by "fighting badgers" (has anyone ever heard of this happening?), veterinary scientists believe that most cats are infected with TB when bitten by infected small rodents while hunting. These rodents in turn would have been infected by sniffing around infected badger setts. When a cat is diagnosed with TB, an owner has always been advised that treatment of the cat may be possible, but the remote chance of a human picking up TB from the cat is something that has to be taken into account when considering doing this. For this reason, many cats diagnosed with TB are euthanased. There is nothing new about any of this: vets have (rarely) been diagnosing TB in cats for many years. The last sentence of the Vet Record report is worth repeating: here it is in capitals in case you missed it: NO NEW CASES HAVE BEEN DETECTED IN LOCAL CATS SINCE MARCH 2013. From the media coverage, you would swear that this was an immediate and present threat to human life. The facts are far less exciting. Following the episode a year ago, due to the unusually high concentration of TB in cats in the area, all humans in contact with the affected cats were offered to be screened for TB. Of 39 people who were offered this, 24 accepted screening, and two people (who had contact with the same cat) were subsequently diagnosed with active TB disease caused by the same TB organism that had affected the cats. Only one person had been showing any symptoms of TB, and both are responding to treatment.  Two other people had some broad evidence of exposure to TB, but there was no evidence to suggest that it was the same TB that had affected the cats. To summarise: two people, over a year ago, were diagnosed with TB that was linked to a cat. Two other people were diagnosed with previous exposure to TB that may or may not have been linked to cats. Meanwhile, 8751 cases of human TB were reported in the UK in 2012, picked up from humans. The message from today's media seems to be: "DANGER: YOU COULD GET TB FROM CATS". The message that they should have given out is far less dramatic: "The absence of reports of confirmed cat to human transmission of TB previously led public health practitioners to consider the risk of transmission as negligible. However, an assessment of this incident raised the risk of transmission of TB from cats to humans from negligible to very low." Or to put it more simply: Up till now, there was thought to be a minimal risk of picking up TB from cats. Based on an incident over a year ago in England, there's now thought to be a very low risk. But that wouldn't make good headlines, would it?

A vet in Delhi day 7: summary and conclusion

[caption id="attachment_3824" align="aligncenter" width="560"]ASHA gave me the opportunity to give a talk to their community health volunteers on rabies ASHA gave me the opportunity to give a talk to their community health volunteers about rabies[/caption] I've spent my final day in the slum and it's time to draw it all together and reach some conclusions. What's it all been about, what have I achieved, and what's going to happen next? First, to explain: the rationale behind my work has primarily been human health. It's shocking that rabies is still a major killer in India, despite the fact that it's completely preventable. If 70% of the street dogs in an area are vaccinated, the disease dwindles and disappears to insignificant levels. Surely this is a goal that is achievable? The current estimated incidence in India of around 3 deaths per 100000 people per year means that over 20000 people, mostly children, die unnecessarily every year. In a slum like Mayapuri, with a population of 12000, there's probably around one death every three years. Feedback from my questionnaire suggested that this may be close to the truth. Rabies is common enough to be a constant threat, but rare enough that it's easy for people to forget about it. Yet it is such an horrific, unnecessary death that everything possible must be done to prevent even one fatality. ASHA deals effectively with many health and welfare issues in the slums, vaccinating children with BCG, MMR, Hepatitis, Tetanus and Polio: before ASHA arrived 15 years ago, no babies were being vaccinated – the uptake is now 100%.  ASHA also treats adults for TB under the DOTS programme, and offers a range of birth control methods. There's no doubt that the charity's work has transformed the lives of the slum dwellers. But what about rabies? When I asked this question last year, it seemed that it was a bit of a grey area: ASHA is so busy with other priorities that it's easy for rabies to slip under the radar. When I discovered this, I felt that there was an opportunity for me to use my background as a vet to look into the issue when visiting the slum with a group of volunteers from my local church. Mission Rabies – who are already in the process of vaccinating millions of dogs around India – do not have an immediate plan to focus on the Delhi area, but they were exceptionally helpful in assisting me with this project. They drafted a questionnaire for me to use while here, and they advised me on important aspects such as informed consent and male/female interpreters. So what did I discover? Well, I found out how difficult it is to do social research. I had thought I might gather several hundred questionnaires over 3 days, but the process took longer than I had expected: up to 15 minutes for each interview via an interpreter, then time spent seeking out the next candidate. I ended up with just 40 completed questionnaires: not as many as I'd have liked, not enough to be significant in a formal sense, but still perhaps enough to gather valuable feedback about the subject. What did I learn? First, I discovered some interesting socioeconomic facts.
  • 75% of households live in just one room, shared between an average of four people: no kitchen, no bathroom, no hot water
  • 95% of slum dwellers own a mobile phone
  • 90% own a television
  • 65% own a bicycle.
Second, I discovered that street dogs are a significant part of the slum community, with an average estimate of one dog per 17 humans (the range was one per 5 to one per 20 people). The only way to get a more accurate figure would be to do a detailed dog census, which would be a major logistical challenge in itself, but the estimates are enough to make the point that there is a substantial population of dogs.. While only 15% of people said that they “owned” a dog, 57.5% said that they feed local dogs at least once a week. This ties in with the reported attitudes to dogs: 40||% said that they “liked” dogs, 15% were indifferent t while 45% of interviewees said that they “did not like dogs” (presumably the latter never feed them). Third, I investigated the local people's knowledge about rabies. I found a low level of awareness of the disease. 80% of respondents had not heard of rabies, and only half of the 20% who said that they had heard of rabies were able to explain the disease to someone else. Some people thought that rabies would make them “bark like a dog”. Furthermore, only 45% of people thought a dog bite could be fatal, with 55% of people disbelieving this. There's clearly a need for community education about rabies in order to prevent future cases. More positively, despite the lack of knowledge about rabies, 90% of people would go to hospital if bitten by a dog (where they would be given the post-exposure rabies vaccination). As well as doing this, some people would take other action, including putting red chilli powder on the wound, and resorting to “witchcraft”. The 10% who “did not know what to do” if they were bitten by a dog are worrying: they would be very vulnerable to developing clinical rabies if bitten. What's going to happen next? If nothing is done, nothing will happen. The situation will remain the same, and people will continue to die of rabies at a rate of around one person every three years. Clearly this cannot be allowed to happen. ASHA already have an effective network of community health volunteers on the ground, keeping an eye on the health of inhabitants in their local area, and passing on information to them about health and disease using handouts and flash cards. On my last day in the slum, ASHA kindly arranged for me to give a presentation to a dozen community health volunteers from Mayapuri and another nearby slum. I was able to pass on the initial results of my survey, and to discuss the challenge of rabies awareness with them. I explained the issues of rabies and street dogs in detail, and handed out several hundred picture-based colour information leaflets about “Getting Along With Dogs” (designed by Mission Rabies). These volunteers will go back to their own areas and will talk to local parents and children, stressing the importance of avoiding dog bites by interacting appropriately with dogs. They'll also mention rabies, the importance of wound cleaning and the need for a visit to a medical centre if a dog bite does happen. So far, so good. But what about the other 58 slum areas (housing 400000 people) under ASHA's care? And what about the other 500-plus slums (with millions of inhabitants) that ASHA has not yet reached? There is a massive population in Delhi that's still unaware of the ongoing threat of rabies. What can be done to reach them? This is where Alliance of Animals and People (AAP) may come in. In an earlier blog, I outlined a visit I made at the start of my Delhi trip to one of their slum programmes in a different part of the city. AAP has a stated aim of working with NGO partners to help children in need: their founder, Bondana Dutta, is an ex-regional director of CRY, a major children's charity. The concept is simple: AAP sends a volunteer to nominated slums to teach groups of children about awareness of the risk of dog bites and the importance of rabies prevention and treatment. AAP also works with local communities to lobby municipal authorities to provide other helpful measures such as rabies vaccination and population control of street dogs. Could an AAP staff member visit ASHA slums like Mayapuri to give regular classes to children, raising awareness of these issues and helping to prevent future cases of rabies? If this generation of young people are educated now about the subject, they will soon grow into a well-informed generation of adults, and the entire slum community will then become rabies-aware. This suggestion may sound sensible, but it isn't always so easy on the ground. In particular, funding is a challenge. AAP staff members are already over-stretched. If extra work was scheduled (such as visiting ASHA slums), a new staff member would need to be recruited, costing at least €3000 per year. And a new initiative like this might also incur extra costs for ASHA. If funding is not there, new projects like this cannot happen. So what do we do about it – people like you and I? Finish this blog and walk away? Or take some positive action to help? I realise that I have just been on the front line of the slums, which makes it all very real and urgent to me. But I am heading home with a determination to follow this through by making a commitment to fund-raise for ASHA and for AAP. Over two thousand people have been viewing these blogs: if each of you donated just €2 per year, that would be enough to provide the financial resources to kick start this type of programme. With a small gift from each of us, the first steps could be taken to eradicate rabies from ASHA slums, and to help the welfare of the slums' street dogs at the same time. I'm happy to help to coordinate a plan like this, but I need your help.Visit our other ASHA-focussed blog and click on the "Donate" button on the top right of the page if you want to make a small donation. And watch this space: I'll let you know what happens.  

Caring for the older cat (part 1) – helping your feline friend through old age

Sammy is 12 years old.  That is a respectable age for a cat, so I was very happy to hear from his owner that he was still very well in himself and she had no concerns at all.  The purpose of my visit was a routine health check and vaccination and based on Sammy’s good report, I was expecting to issue him with a clean bill of health.  However as I began to collect a thorough history, it became apparent that things were not as simple as they had first appeared.  ‘Now that you mention it, Sammy HAS been drinking more than he used to, but I thought that was normal for older cats so I didn’t think twice.’  He had also had a great appetite lately, in fact he’d been eating an extra pouch a day, and he had been more talkative lately.  All things that his owner had associated with good health but could actually be signs of illness.  On physical exam it turned out he had lost some weight and muscle mass, and that he had a lump under his neck.  A blood test was recommended and the results confirmed hyperthyroidism.  He was started on medication and is now back to his normal self, his owner couldn’t believe the difference!  She was surprised how the changes had happened so gradually that she didn’t notice them, but was very happy to have her old cat back.  And Sammy certainly agreed. The above scenario is not at all uncommon.  Cats are experts at hiding their illnesses, and sometimes they can become very poorly on the inside whilst appearing relatively normal on the outside.  And as in Sammy’s case, sometimes the changes that do happen occur so slowly that we just assume it’s a normal part of aging. He’s turned into such a ‘grumpy old man’ One of the best examples of this is an older cat’s ‘grumpiness’.  It’s easy to assume that older cats have been through enough and now just want to be left alone, but could there be a cause for their change in attitude?  Perhaps they can’t see or hear as well as they used to and are more frightened by strange sights or sounds.  Maybe they have severe dental disease that causes them to hide away or change their eating patterns.  Is arthritis the reason behind their dislike of the brush or even your previously adored petting strokes?  These conditions frequently go unnoticed except for a change in behaviour, yet if diagnosed, there are many things we can do to make them more comfortable. She just can’t seem to ‘hold it’ anymore Another common but decidedly abnormal symptom is a change in urination or defecation patterns.  ‘She just can’t seem to make it to the litter tray anymore, bless her’ is a common complaint, yet one that doesn’t always get brought to the vet’s attention.  Cats are clean, proud creatures and don’t generally wet or soil the house without good reason.  Perhaps she has kidney disease and is having to cope with large volumes of dilute urine.  Could arthritis again be the cause behind her new dislike of the litter tray?  Small, covered or high-sided litter trays can be a nightmare for cats that find it painful to position themselves to defecate.  Maybe she has diabetes and the sugar in her urine has brought on a bladder infection.  Changes in urination or defecation should always be brought to your vet’s attention as there is usually an underlying cause. All he ever does is sleep these days Now I am the first to admit that I do not have as much energy as my 3 year old.  And my grandmother frequently complains that she’s not able to get out and about as much as she used to.  The difference between my son and I is mainly the 30 year age gap.  But my grandmother’s reasons may have more to do with her failing eyesight and worsening arthritis.  It’s certainly true that kittens are more active than their more mature housemates, and that some slowing can be expected with age.  But when your previously active older cat starts to sleep 23 hours a day instead of her usual 20, what might seem like a small change to you could indicate a big problem.  High blood pressure can cause depression and lethargy and can also result in blindness, making affected cats less likely to venture from their bed.  A cat who used to love going outdoors may find the cat flap too painful now that arthritis has set in.  Anaemia (not enough red blood cells carrying oxygen around the body) and its associated decrease in energy levels is another symptom that frequently goes unnoticed. Some alarming statistics In a recent study of older cats brought to the vet for routine vaccination, one third of those described as ‘completely healthy’ by their owners were found to be suffering from significant diseases such as kidney disease, high blood pressure or hyperthyroidism.  Two thirds had abnormally dilute urine, an early warning sign for kidney disease.
  • Chronic kidney disease is estimated to affect about 30% of cats over the age of 15
  • 10% of cats over the age of 9 are thought to suffer from hyperthyroidism
  • Cognitive dysfunction (a deterioration in brain function giving cats Alzheimer’s-like changes in behaviour) is estimated to affect over 50% of cats over the age of 15
And perhaps most alarmingly, a staggering 90% of cats over the age of 12 (which is not that old really) are thought to suffer from arthritis.  Only a tiny fraction of these cats are ever brought into the vet because they appear painful, and only a small percentage of those receive regular treatment for their pain. ‘Common’ does not mean ‘normal’ I think the most important thing to keep in mind is that although some things like drinking a bit more or losing a bit of weight may be COMMON in older cats, they are not NORMAL and may in fact indicate discomfort or illness.  If diagnosed (particularly if caught early), most of the above conditions can be treated successful and for those that can’t be cured, we can at least provide care that can dramatically increase the quality of their lives.  I’ll talk about some of the things we can do to help our aging feline friends next time but in the meantime, take a good long look at your older cat and think about some of the changes that might be taking place inside that they may not be telling you about.  If you discover anything that causes concern, bring it to the attention of your vet.  Sure, your grumpy old man may not enjoy being dragged out of his bed and into the vet (don’t be afraid to ask your vet if they would be willing to make a home visit), but the possibility of a more comfortable life far outweighs the temporary inconvenience.  Your cat has nothing to lose and everything to gain! If you are worried about any aspect of your cats health, please book an appointment with your vet or use our symptom guide.
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