VetInfo Digest November 1997
This issue
Vaccination Protocols
Current Issues in Pet Health Care
Health Alerts
Pain Relief
Getting Ready for Emergencies
It has been necessary to make some changes at our VetInfo website. As you may have noticed by now, we are no longer offering the "AskDrMike" column as a free service. Our site receives over 200,000 hits per month and many of the people who visited took the time to send a question. Dr. Richards was simply overwhelmed by the e-mail and felt it was unfair to allow people to expect a reply when it was not possible to reliably supply one. We have been searching for sponsors for the site without too much luck and economic realties are starting to set in, as well. Consequently, we are going to limit replies to people who support our site and this newsletter by subscribing. We hope that will enable us to continue to interact with pet owners and to accurately report the issues they are interested in while reducing some of the personal stress. We really do thank all of you who are supporting our efforts with your subscriptions!
Vaccination Protocols
Vaccinations have been the cornerstone of veterinary preventative health measures and have become a significant portion of almost every veterinary practice's income. Their obvious success in improving the health of pets and the security of having a "hook" to bring clients back from year to year made vaccines very important to pets and to veterinarians. Their success has brought new problems to veterinary medicine, though.
It is very tempting to consider vaccines as totally benign medications. I have heard the phrase "they can't hurt and they might help" uttered by more than one veterinarian while discussing vaccinations. It would be great if this were true, but it is not so. Vaccines can and do cause reactions, some of them severe. Their normal effects include platelet suppression, soreness at the vaccination site and a short-term decrease in immune competency. Occasionally they cause anaphylactic shock or severe delayed reactions with more profound immune suppression than usually occurs. A few patients suffer abcesses at the injection site. Cats appear to develop fibrosarcoma tumors at vaccine injection sites more frequently than they would otherwise be expected to occur. At present, it appears that these tumors arise in about 1 in 3500 cats after vaccination.
Parvovirus is a deadly disease. It is horrible to see a dog or cat with distemper in a veterinary practice. I can remember patients with viral hepatitis, leptospirosis and other illnesses routinely prevented by vaccination and I would not like to return to the days before vaccines were readily available. It is easy to understand why many veterinarians are very reluctant to change vaccine protocols or to even admit that problems can occur. It was easier to take this stand prior to the release of studies from Cornell University recently which showed that vaccines for rhinotracheitis, calicivirus and panleukopenia had a much longer duration of immunity than the one year duration assumed by most vets.
It is apparent that vaccines do have some risks associated with them. It is equally apparent that the diseases they protect against are also a major risk. A less apparent risk to pets is the effect of lengthening the time between vaccinations on their overall health. Most pet owners do not carefully examine their pets for early signs of disease or for medical problems such as abcessed molars or ear infections which are inapparent without a real search. An examination once a year by a veterinarian can help to stop problems early when they are most easily treated and can help in management of more chronic conditions. Veterinarians are going to have to figure out a way to separate the yearly physical exam from the vaccinations in order to ensure that their patients get the best of care.
Risk assessment is going to become a very major part of the health care of pets in the near future. Instead of having standard vaccination protocols for all pets, it is likely that there will be protocols more closely tied to the lifestyle of each individual pet, based on their individual risks. Dogs who do not go outside are not likely candidates for Lyme disease, for instance. The same is true for cats who stay indoors away from carriers of feline leukemia virus. For these pets, the odds of a significant reaction are higher than the odds of contracting the diseases vaccines are meant to protect against. The situation is entirely different for a hunting dog in Connecticut or a cat who rigorously defends an outside territory, though. It is very likely that these pets will be exposed to diseases that can be prevented through vaccination. The "risk to benefit ratio" favors using vaccinations as often as is necessary to maintain adequate protection in this case.
What will the guidelines be for risk assessment? Right now, this question is still being debated among veterinarians at all levels of practice. There do appear to be some guidelines that are not too controversial, though. First, puppies and kittens should be adequately vaccinated against the common canine and feline diseases. This usually takes at least two vaccinations and often more than that. Very few veterinarians recommend skipping vaccinations altogether. There is pretty clear evidence that the vaccinations for cat diseases, other than possibly feline leukemia vaccination and feline infectious peritonitis vaccination, last at least three years. A very active outdoor cat might still be a candidate for yearly updates but most other cats can go three years between vaccinations. For the most part, feline peritonitis vaccination is only recommended for multi-cat environments in which there is a steady influx of new cats. Parvovirus vaccination probably lasts lifelong in dogs, after it is successfully accomplished. This is paradoxically one of the harder vaccinations to get good immunity from, so puppies often need to be vaccinated several times to ensure vaccine success. The longevity of canine distemper vaccination appears to depend on the strain of virus used, varying from one to two years to as long as lifelong. Vaccination for leptospirosis has fallen out of favor with many veterinarians due to the increased problems with reactions to this portion of the vaccine than to other portions and the short duration of immunity of less than one year. In the meantime, leptospirosis also appears to be making a comeback in the U.S. Unfortunately, the strain of the bacteria causing much of the problem is not included in any vaccination combinations currently available. The resurgence of this strain does make vets wonder if skipping the vaccinations for leptospirosis might lead to future problems with the usual strains, though. It will be important to monitor the prevalence of diseases for which vaccines exist as changes are made in the vaccination protocols.
Your veterinarian will probably begin to discuss these issues during future yearly physical exams. Please remember that the exam itself is important and that it is really what you have been paying for when bringing pets in for "yearly vaccinations" over the years. If your vet isn't discussing these issues with you, consider asking about them. It may be much better to put the money spent on vaccinations in many pets into reducing other risks. Teeth cleaning, monitoring serum chemistry values as pets age, behavioral consultation or other procedures previously felt to be less important than vaccination may turn out to be the next really big improvement in the over-all health care of dogs and cats.
Current Issues in Pet Health Care
Should you put your cat on heartworm preventative?
Many of my clients have seen the television ads and have asked about this. The answer where I live is pretty easy. Mosquitoes are a constant feature of warm weather months along the shores of the Chesapeake Bay and heartworm disease is still very common here. In my practice area, if a client doesn't mind spending the money and their cat goes out at all, we recommend heartworm preventative. We have found ourselves waiting for the client to ask about these products, though. The enthusiasm among clients has been less than we expected and even veterinarians get tired of rejection and give up on pushing health care advances sometimes.
The answer is even harder in areas with a lower prevalence of heartworm disease. I have seen a couple of studies on the prevalence of heartworm disease in cats and it seems, quite unscientifically, that the prevalence is about 10% of that seen in dogs in the areas studied. Given this, it should be possible to figure out a rough estimate of the risk to the "average" cat in your area. If you are lucky enough to live in an area in which heartworm disease affects only about 10% of dogs not on preventive medications, then the risk to a cat in the same area is probably about 1%. At these odds, spending the money on preventatives may not seem a like a good use of funds for veterinary care, if those funds are limited. If you hear about heartworms at bridge games, cocktail parties and PTA meetings because they are so common in your area, then your cat is a lot more likely to be exposed if he or she lives outdoors even part of the time. You should strongly consider heartworm preventive medications for cats, in this case.
What should I do about leptospirosis now that there are outbreaks in many areas of the country?
There have been a couple, or perhaps several, reported outbreaks of leptospirosis recently. This is a bacterial disease caused by a number of strains of leptospirosis bacteria. Kidney and liver damage are the most common results of infection and symptoms relate to loss of function in these organs. Affected pets may have vomiting, depression, lack of appetite, fever, dehydration and/or abdominal pain. If the liver is severely damaged there may be visible jaundice and kidney damage may lead to an increase in drinking and urinating. Other disease symptoms can also occur. Some of the dogs infected in the recent outbreaks were previously vaccinated against leptospirosis. This has been a major concern for pets participating in pet shows and other events, as well as for pets traveling to areas in which outbreaks have occurred, such as Long Island, NY.
There are a large number of recognized strains of Leptospira bacteria. There may be over 200 different strains with the ability to cause disease. The bacterins that are used in combination vaccines for dogs usually only include one or two strains of the bacteria, the L. icterohaemorrhagiae and L. canicola strains. The L. grippotyphosa strain was implicated in the Long Island outbreak and there is not an available bacterin for this strain. Other strains, such as L. pomona and L. hardjo have been implicated in other outbreaks in the past. The leptospira bacteria are most commonly involved in infections when the environment is wet, especially after heavy continuous rainfall or floods. Dogs and humans are probably infected most commonly by exposure to bacteria spread by rodents.
The available vaccinations protect against the most common strains of lepto based on past infections. Currently there seems to be a change in the most commonly recognized types of infections and no bacterins are available. The duration of immunity after vaccination appears to be pretty short, possibly as short as six months. Anaphylactic (sudden shock) reactions to leptospiral vaccinations is more common than to other vaccine components. All of this seems to make vaccination for leptospirosis less important. On the other hand, the success of vaccination may be the reason for the change in the type of infections seen. When everything is weighed, it is probably a good idea to consider vaccination for this bacteria if there is a good chance of exposure to wet conditions and water contaminated by rodent urine. In these areas, vaccination may only be successful over the long term if it is boostered twice a year. There is no vaccine for many strains of leptospirosis so it is also imperative to limit exposure of pets to flood conditions and standing water, especially if it may be contaminated by the urine of wild animals, especially rodents. In many areas of the country, the incidence of this disease is low enough that the risk of reactions is higher than the risk of the disease. Your vet may or may not vaccinate routinely for this condition. Whichever way you wish to go on vaccination, it may be worthwhile to ask your vet if leptospirosis vaccination is a normal part of their vaccine protocol.
A high degree of suspicion for leptospirosis should be maintained when vomiting, increased drinking and urinating, depression and lack of appetite are present. Laboratory values suggestive of liver or kidney damage should also prompt consideration of this disease as a potential problem. Catching it early and treating appropriately does seem to help a great deal in limiting the damage this disease can cause in pets.
Health Alerts
If you have a dog with incontinence that has been controlled with diesthylstilbestrol (D.E.S.), you may have found your vet can not supply this medication anymore. The tablets of this are not currently available, as far as I can determine, from veterinary suppliers. Compounding pharmacies can usually still make D.E.S. capsules from the powder. It is more expensive but your vet can write a prescription if you have tried phenylpropanolamine or Premarin (Rx) and found them to be less effective alternatives.
This is the time of year when antifreeze poisoning is more likely to occur. When changing antifreeze or adjusting antifreeze levels in your car, clean up any spills to avoid possible poisoning of pets. If a pet does drink antifreeze, there is a new treatment available (Antizole Rx), which is reported to be more effective than the older method of treatment. There are also antifreeze compounds available which are not ethylene glycol based and are safer for pets.
The Wall Street Journal recently ran an article that was critical of the relationship between Hill's, manufacturers of Science Diet and Prescription Diets, and veterinarians. It is probably true that your vet is not a nutritional expert -- most are not. It is also true that what is unknown about dietary requirements probably surpasses what is known about them. Your vet is as susceptible to nutritional misinformation as you are. So take the time to think about nutritional recommendations from your vet. Prescription diets are not always nutritionally complete. If your pet is less than one year old, pregnant or recovering from a debilitating illness it may be harmed by inappropriate use of prescription diets. It is worth calling the 800 phone number on the bag if your pet falls in one of these categories and is on a prescription diet. Vets are human, too ---- don't forget to be an informed consumer!
Pain Relief
You may find that you have to push just a little harder for pain relief medications for your pet post-surgically and in other situations in which pain control seems necessary. Butorphenol (Torbugesic SA, Torbutrol, Rx) has been reclassified and is now a controlled substance. This means that veterinarians will need to track the use in logs and some will opt to skip the pain control rather than doing additional paperwork. There are good alternatives that are not controlled drugs for dogs but the options for pain relief in cats are limited and this does place an extra burden on vets using pain relief medications routinely.
Another story from our hospital
Michal, our website designer, is also one of our receptionists. Her favorite client story involves a client who came in for a rabies vaccination after an encounter with the local animal warden. This client was absolutely totally unaware of the health care needs of her pet. Michal spent a good deal of time discussing rabies vaccination, heartworm preventatives, deworming and other health concerns. Finally, she got down to asking specifically what the client wished for us to do on that particular visit. When she asked "Do you want Dr. Richards to vaccinate your dog for distemper, too?", she was nearly incapacitated by the reply. "That sounds like a really good idea. He has a TERRIBLE temper!" Michal is usually pretty good at hiding her reactions to odd client questions or statements but she did spend a really long time with her head under the desk, fooling with her shoelaces after that one.
Getting Ready for Emergencies
No matter how dedicated your veterinarian is there are going to be times when he or she can not be there for your pet's emergency. It is critical that you know, in advance, what you are going to do when that happens. It is best to have written information readily available so that everyone in the family can deal with an emergency as calmly and as efficiently as possible.
First, talk to your vet or your vet's staff about their recommendations for dealing with emergency situations. Some veterinary hospitals utilize an answering service and offer emergency services at their hospital, as long as they can be contacted. This works pretty well as long as there is not a need for extremely prompt action. Other veterinary hospitals always refer you to an emergency veterinary clinic (EVC). This irritates many pet owners but in most real emergencies it is better for the pet. The EVC is usually fully staffed, often has better equipment for dealing with emergency situations and usually can provide attended aftercare, something that is very hard for solo practitioners or small veterinary hospitals to provide. Even if the clinic is a half-hour away it is often just as quick to drive directly there as it is to make arrangements to meet your vet and wait for both of you to arrive at the veterinary hospital. Know the phone number of the EVC and keep it posted by your phone. Make sure that you know how to get there. It is best to drive by the facility during the day and at night to make sure you can get there in an emergency. It is even better to stop by and see the facility and meet the staff members but do remember that these facilities are for emergencies and that there will be times when staff members will be too busy to give you a tour or to discuss payment polices in detail.
You do need to know the payment policies prior to an emergency, though. One of the biggest problems in veterinary medicine is that emergency care is often expensive and that decisions about this care must be made under duress. If you are prepared to leave an adequate deposit or can pay the bill by credit card there should be no problem dealing with the EVC staff quickly in an emergency. Just make sure that you know how much money you will need to have on hand for an emergency or if the EVC will work on credit if that is necessary. Emergency procedures can be hard to collect payment for, so many emergency veterinary clinics are pretty tough about requiring deposits. Be prepared.
Even if your vet provides emergency services you should know the location of the nearest veterinary emergency clinic. If it is quicker to go there, do not wait for your vet to call back if your dog is bleeding profusely or having great difficulty breathing. These situations require you to know where emergency help is available and to proceed there as quickly as possible. If you can, have someone notify the emergency clinic of the problem and your estimated time of arrival there. Do not drive to your veterinarian's office expecting her to be there at odd hours. Doing this wastes time and can cost your pet's life.
Most dogs and cats will bite when they are in severe pain. Since this is often the case in emergency situations, be prepared to handle this. An excellent way to keep a dog from biting is to use a gauze muzzle. Using one of the new stretchy gauze products, such as Kling (TM) or Conform (TM), cut about a three foot piece of gauze and tie a simple overhand knot in it. This makes a big loop. Put this over the dog's muzzle, keeping your hands well away from the dog's mouth. Tighten the loop down, tying the dog's mouth shut. The knot should be on top of the dog's muzzle. Make a second loop and place it over the dog's muzzle with the knot under the chin. Tighten it down, too. Then tie the two ends of the gauze behind the dog's ears. I keep a roll of gauze in my glove compartment so I have it when I see a dog that has been hit by a car. For cats, a big towel or small blanket can be used to cover the cat. Most will settle down when covered. Then push the sides under the cat and pick up the whole bundle. Be extremely careful if you are handling pets you do not know! If the animal is very upset or seems very likely to bite or scratch it is best to call for help. 911 works in many localities to obtain the help of an animal warden.
Don't panic in an emergency. The reality of veterinary medicine is that most pets that die in the first few minutes after a severe trauma would die even with the best of veterinary care. Those that survive longer are probably going to live long enough to make it to the veterinarian's office, even if it is the next day. Do your best to get your dog or cat to an emergency care provider but do not risk your own life or the lives of other drivers and pedestrians on your way to your vet's or to an emergency veterinary clinic.
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