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

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

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

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

5. Diagnostics Humans Signs & Symptoms Tick exposure history EIA / Western Blot Other serology, lymphocyte assays, joint fluid tests not recommended Dogs SNAP point-of-care ELISAs Quantitative C6 antibody assay Urinalysis Urine protein-creatinine ratio Photo credits: University of Michigan Medical School, www.lymeinfo.ca

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

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

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

9. Practice Location No.% Maryland county (n=191) Anne Arundel 2915.8% Montgomery2915.8% Baltimore City189.8% Other counties11558.6%

10. Practice Characteristics Number of vets in practice (n=180) 1 to 3 763.8% 4 or more10457.8% Practice type (n=183) Exclusively small animal 16590.2% Mixed animal116.0% No. % Photo Credits: Woodlake Animal Hospital, Redmond Vet Clinic

11. Veterinarian Perception of Canine LD Risk Perception of risk for canine LD (n=191) High Risk 11459.7% Moderate Risk7137.2% Low Risk 21.0% Not At Risk 00.0% Other42.1% No. %

12. Use of LD Screening Tests Screening with which Lyme disease test (n=148) Idexx SNAP 4Dx 11779.1% Idexx SNAP 3Dx128.1% Antech Accuplex panel1711.5% PCR 00% Other 21.4% No. % Photo credits: Idexx, Antech

13. Frequency of LD Screening Frequency of LD Screening (n=145) Annually14576.3% Only with clinical signs2312.1% No screening recommended31.6% Other1910.0% No. %

14. Reasons for Annual Screening Reason for annual LD screening (n=155) (multiple answer selections possible) Endemicity of disease12781.9% Tracking seroprevalence4629.7% Informing dog owners7246.5% Annual heartworm testing, with LD test included 6038.7% Other42.6% No. % Photo credit: CDC

15. Reasons for Not Recommending Annual Screening Reason to not recommend annual LD screening (n=35) (multiple selections possible) Test does not diagnose or predict disease 1748.6% Overdiagnosis/ overtreatment 1440.0% Expense of treatment38.6% Antimocrobial resistance 617.1% Unnecessary owner distress 617.1% Other1028.6% No.% Photo credit: www.iran-daily.com

16. Follow-Up Diagnostic Testing If perform follow-up tests, which tests recommended (n=59) (multiple answer selections possible) Quantitative Lyme C64271.2% Urinalysis3864.4% Urine Protein:Creatinine Ratio 1728.8% Serum Chemistry/CBC2033.9% Other46.8% Is urinalysis follow-up repeated annually? (n=60) Yes3253.3% No1830.0% We do not perform UA for dogs screening positive 1016.7% No. %

17. Management of Asymptomatic, SNAP-test Positive Dogs Treatment of asymptomatic dog screening positive (n=149) Treat all positive dogs with antibiotics 117.4% Treat the first time screening positive, then based on clinical signs 5536.9% Perform follow-up testing5939.6% No treatment or follow-up without clinical signs 96.0% Other 1510.1% No.%

18. Lyme Vaccination Do you use a Lyme vaccine (n=187) Mandatory, core vaccine6032.1% Vaccinate if high risk8847.1% No Lyme vaccination42.1% Other3518.7% No. % Lyme vaccine brand used (n=182) (multiple selections possible) LymeVax, Zoetis3921.4% Recombitek Lyme, Merial8747.8% Duramune Lyme combo, BI 4323.6% Other2513.7%

19. Associations Treating asymptomatic positive dogs with antibiotics Annual Screening YesNo Chi-squared p-value Yes6878 0.067 No30 Photo credit: www.crossingthinice.comwww.crossingthinice.com

20. Conclusions ACVIM recommends weighing benefits and risks of Lyme disease screening 76.3% of veterinarians screen annually ACVIM recommends case-by-case decisions: treatment of asymptomatic positive dogs 7.4% veterinarians treat all asymptomatic positives 36.9% of veterinarians treat all dogs at first seropositivity ACVIM does not recommend vaccinating seropositive dogs Majority (79.2%) of Maryland veterinarians recommend Lyme as core vaccine or recommend if patient at high risk 96.9% feel patients are at high risk How many are seropositive at time of vaccination?

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

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

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