Student guest post: Mission Impossible: Fighting Zoonotic Infections in Nicaragua

Student guest post by Brandon Woods

A Dangerous Paradise

From jungles with jaguars to crystal blue lakes with freshwater sharks, Nicaragua is one of the most beautiful and dangerous countries in Central America. The brilliant biodiversity attracts millions of tourists each year and the looming volcanoes that pepper the landscape can be an exciting yet unsettling sight. However, in reality much of the danger in Nicaragua comes from the risk of infectious diseases. For example, if you’re planning to travel to this tropical paradise anytime soon, the Center for Disease Control (CDC) states that international travelers are at risk of contracting Typhoid fever, hepatitis A, hepatitis B, Leishmaniasis, malaria, dengue, rabies, and more! As a dual degree veterinary medical and public health student, I am fascinated by these infectious diseases and want to learn how they interact with the environment, people and animals. Many of the diseases that the CDC listed are called zoonotic diseases, or diseases that are transmissible between animals and humans. Other zoonotic diseases you may know include ringworm, Lyme disease, and Cat scratch disease. Whether you own a pet, like to travel, or simply enjoy spending time outdoors, you are at risk of infection because these zoonotic diseases are increasingly emerging worldwide and are becoming a serious public health threat. During the spring break of my first year of veterinary school, I traveled to Nicaragua on a mission trip and got first-hand experiences of these frightening infectious diseases.

 Brandon picture 1

Bed Nets and Bug Spray

Planning for this trip was time-intensive and reminded me of planning for my semester study abroad adventure to Tasmania, Australia. However, unlike my semester Down Under, this trip was coordinated through the national non-profit Christian Veterinary Mission (CVM) whose goal has been to help veterinarians serve others and live out their Christian faith for more than 30 years. Out of all the fundraising and logistics meetings we had, the meeting that stands out the most was when the Iowa State University travel nurse described the laundry list of potential pathogens we could encounter. Our team of 8 veterinary students, 3 veterinarians, and 1 pharmacist would be treating animals in a remote village called Espavel in the jungles of eastern Nicaragua. When I saw that my destination was in the middle of the red zone for malaria on the CDC map, my eyebrows escalated and my stomach dropped.

I was going to fly to an unstable, earthquake-prone country of approximately 5.7 million Spanish-speaking people where malaria was endemic. My Spanish was scarce, but my drive to serve was strong. After I heard that malaria was essentially eliminated from Nicaragua, my blood pressure dropped a few millimeters of mercury. Approximately 84% of the Nicaraguan population is at risk of contracting malaria, according to a UCLA study. However, Nicaragua has experienced a 97% decrease in reported malaria cases between 2000 and 2010. This significant decrease in prevalence was a result of Nicaragua partnering with the Pan American Health Organization (PAHO) in 2006 which heavily implemented stronger surveillance, prevention, vector control, and treatment. Despite this progress, I learned from my undergraduate Lyme disease Honors project that there are always numerous challenges to completely eliminate vector-borne diseases like malaria. For instance, controlling mosquito breeding populations is particularly vexing due to the complex ecology of the parasite life-cycle. In addition, you may have heard about the controversy surrounding toxic pesticides like DDT. My colleagues and I were fortunate for our DEET bug spray and Permethrin treated clothes and bed nets that we brought after skyping our host-country missionaries. I was also relieved that our trip in March 2013 was during the dry season and not during the September-to-January rainy season, when disease transmission is highest.

Rambunctious Rabies

Escaping the endless hours in the frigid, formaldehyde laden anatomy lab and flying to a third-world tropical country to practice preventative medicine was slightly shocking, but totally worth it. On our first day, we drove through the littered streets of Catarina to an outdoor shelter where we set up a temporary clinic. The local children brought their pet dogs and we treated them with Ivermectin and other anti-parasitic medication. Many animals were very thin and infested with fleas and ticks. However, it was rewarding to interact with the children and walk them through a brochure that described both healthy animal care and the Gospel of Jesus Christ. Then suddenly one of my colleagues was bitten by a dog! He was trying to give a rambunctious mixed-breed a pill to protect against heartworm disease and the next thing he knew, the dog bit him in the hand. He quickly washed the wound with soap and water and bandaged it. Fortunately, everyone on our veterinary team was already vaccinated for rabies prior to the trip because it’s a requirement to enter veterinary school. He also followed up with post-exposure rabies prophylaxis when he returned home.Brandon picture 2

Rabies is one of the deadliest and most notorious zoonotic diseases in the world. Rabies is endemic to Nicaragua, often occurs in poor rural communities, and the most common source of transmission is when a dog bites a human and delivers the fatal RNA virus. According to the World Health Organization, potentially any mammal can contract rabies, and common reservoirs in the USA include skunks, foxes, raccoons, and bats. Although rabies cases can be successfully treated, it still persists worldwide killing more than 55, 000 people each year. The Center for Food Security and Public Health (CFSPH) at Iowa State University is an excellent resource that provides more information on rabies and preventing zoonotic diseases. Reducing the prevalence of rabies globally requires a multinational effort and the World Rabies Day Initiative was founded solely for this mission and has already collaborated with 150 countries and vaccinated over 7.7 million dogs.

Tasting Iguana and Tackling Typhoid

It’s a good thing I like rice and beans, because that was the bread and butter of most of my meals every day. Hiking to farms builds an appetite and one day we had to traverse across a narrow blank that stretched precariously over a ravine. After we arrived, we vaccinated over 100 head of cattle for clostridium, anthrax, and Dectomax. Dectomax is an injectable drug used to control parasites like hookworms, round worms, grubs and mites. When we returned to the main village and got out of the blazing 90+ degree sun, the crispy, plantain chips with a glass of freshly squeezed tamarind juice was an irresistible snack. However, the most memorable meal of all was the morning the villagers surprised us with two 5 foot long iguanas! A few hours later, I was savoring some delicious iguana meat seasoned with local spices and vegetables. Cooking wild reptiles is foreign to us in the developed world; likewise, the way many Nicaraguans prepare their food is also different.

Brandon picture 3

Sayings like, “Don’t drink the water,” or ‘Boil it, cook it, peel it or forget it,” come to mind when traveling abroad, and they couldn’t ring more true for my experience. Food-borne illnesses are another great example of how veterinary medicine and public health overlap. I’m enrolled in the dual DVM-MPH degree program at the University of Iowa’s College of Public Health and learned that food-borne epidemics are a major focus of research in epidemiology. From mild cases of spoiled potato salad on romantic picnics to church dinner outbreaks from contaminated home-made ice cream, food-borne illnesses can range in their severity depending on your pre-existing health and the dose and type of microorganism ingested. One of the Nicaraguan diseases that I was vaccinated for before my trip was a food-borne illness known as Typhoid fever. Thankfully I avoided this illness; however, I couldn’t escape the wrath of Montezuma’s revenge, or traveler’s diarrhea, most commonly caused by enterotoxigenic Escherichia coli.

Typhoid fever is transmitted through contaminated food or water and is unique among food-borne pathogens because it only affects humans. In fact, some individuals can unwittingly become carriers of the bacterium and transmit the disease to others through improperly prepared food, like the infamous Typhoid Mary. This disease is caused by the bacterium Salmonella typhi, which is one of over 2,300 species of Salmonella and can be treated with antibiotics, according to the USDA. Other Salmonella species are also common among household, cold-blooded critters like turtles, frogs, iguanas, and snakes, so it’s important to always wash your hands after handling these pets.  Like malaria and rabies, Typhoid fever presents challenges for eradication in developing countries where poverty limits accessibility to clean water, pasteurization, and proper sanitation and hygiene. For example, I had never taken a well-water bucket shower before, and although the murky water felt refreshing after a long days’ work, I came to more deeply appreciate the luxuries of everyday plumbing and electricity.

Collaboration is Key

An empowering lesson that continues to inspire me was when I participated in a humanitarian collaboration. Before our departure, we communicated with another mission team from an Arkansas Baptist church that would work at the same time as our Iowa State Christian veterinary mission team would work over spring break. The goal of the Arkansas team was to provide humanitarian care while the goal of the Iowa State team was to provide veterinary care. For instance, the Arkansas team brought donated shoes and eyeglasses, provided nutrition education and had a dentist and nurse that pulled teeth. On the other hand, the Iowa State team vaccinated dogs, cats, horses, cattle, and pigs, performed surgeries and provided agricultural advice to farmers. Even though the two teams set up separate clinics to work on different species, we still felt united as one team because we traveled together, ate meals together, and worshiped together.

Brandon picture 4

One sunny afternoon, we asked the human dentist to come over to our animal clinic to pull a rotten tooth out of a horses’ mouth. The dentist had hardly been around horses in his life, let alone stuck his hand in one’s mouth before, but after the novelty wore off, he quickly agreed to help our team. The sedated horse was lying on its side surrounded by curious villagers and veterinary students. The dentist was nervous and the 3 inch long decayed molar kept wiggling out of his grip. Finally, he extracted the tooth and everyone was amazed and overjoyed. It’s a simple story like this that showcases the successful collaboration between veterinarians and other medical professionals that is the goal of the One Health Initiative or the new concept of interdisciplinary healthcare collaboration. In order for us to eradicate these infectious diseases and save lives, it is vital that veterinarians, physicians, dentists, and epidemiologists collaborate and communicate to find solutions.

A Future Fighting Infections

Going on this short-term veterinary mission trip put me in harm’s way, but it gave me real-life experience with infectious diseases, deepened my faith, and strengthened my clinical skills. It was bittersweet to say adios to my amigos, but I know I’ll return to that perilous paradise.  I enjoyed the international fieldwork and cross-cultural partnership because it embodies the One Health Initiative that I highly esteem. From hiking in the jungle on my 23rd birthday to taste-testing iguana to teaching children about pet care and the Word of God, this trip was a remarkable adventure that has forged a new trail for me. I don’t believe it’s an impossible mission, and I am committed to pursue veterinary public health as a career and control zoonotic diseases in developing countries.

All photos courtesy and copyright Brandon Woods. 

Resources:

http://www.who.int/en/

http://new.paho.org/hq/

http://www.merckmanuals.com/vet/index.html

http://www.cfsph.iastate.edu/Zoonoses/

https://www.cia.gov/library/publications/the-world-factbook/geos/nu.html

http://www.fsis.usda.gov/factsheets/foodborne_illness_&_disease_fact_sheets/index.asp

http://amestrib.com/sections/news/ames-and-story-county/student-traces-lyme-disease-ames.html

http://wwwnc.cdc.gov/travel/destinations/traveler/none/nicaragua

http://www.fda.gov/forconsumers/consumerupdates/ucm048151.htm

http://www.cvmusa.org/Page.aspx?&pid=183

http://en.wikipedia.org/wiki/Zoonosis

http://www.worldrabiesday.org/

http://www.onehealthinitiative.com/

http://www.public-health.uiowa.edu/epi/

“Rabid” by Bill Wasik and Monica Murphy

Rabies is a disease without a public relations firm. In developed countries, human disease is incredibly rare–we see typically one or two deaths from rabies each year. In contrast, lightning is responsible for about 60 deaths each year. However, worldwide, rabies is another matter. Today is World Rabies Day, a reminder that 55,000 people still succumb to this virus every year–most of them in impoverished regions of Africa and Asia. While cases in the U.S. are typically due to wildlife exposure (rabid bats or even beavers or rabid kitten), infected dogs remain the main vector of infection in most rabies-endemic countries.

In a new book, “Rabid”, Bill Wasik and Monica Murphy have penned an ambitious history of rabies. It’s subtitled, “A cultural history of the world’s most diabolical virus,” and this emphasis makes Rabid unique. Indeed, while the recognition of the rabies virus is just a bit over a hundred years old, Wasik and Murphy trace the infection back to antiquity. The first half of the book is, as promised, a cultural history–4,000 years of literature references to rabies, hydrophobia, “rage” disease, and dog- and bat-borne contagion in places as far-flung as various mythologies (Greco-Roman, Christian, and Egyptian, to name a few); medical literature from Aristotle to Pasteur; and even the vampire myths from medieval times up to Sesame Street’s Count. Wasik and Murphy explore the animal metaphors used for millenia and examine them through the lens of rabies infection, as well as colorfully explain the various (mis)understandings of the virus and rabies epidemiology in ancient texts. Though Rabid is certainly a pop-science book, many portions of the book wouldn’t be out of place in various literature, history, and even religion classes, which again lends to the book’s eclectic flavor.

The latter half of the tale, then, focuses more narrowly on the science of rabies, covering Pasteur’s work toward a vaccine; the (rather late) discovery of bats as the ultimate reservoir of the virus; the challenge to mount vaccination campaigns in resource-poor areas, and the lingering fear of rabies to this day, which is sometimes justified and sometimes not. They also cover the controversy over the Milwaukee protocol as a treatment for symptomatic rabies, and the problem of rabies control.

Finally, Wasik and Murphy note that even today, almost 130 years after the development of the rabies vaccine, control of rabies among the biggest human source of disease–infected dogs–is almost as poor in some places as it was during pre-vaccine England. The methods to control it are, in some cases, also equally barbaric. The introduction of rabies into Bali in 2008 led to a mass cull of dogs, shooting many in the street. Eventually, a science-based vaccination strategy was adopted and seems to be helping, but not before well over 100,000 dogs were culled and several hundred people had been killed by the virus. Rabies may be an ancient disease, but it is a scourge that is still threatening us where government lacks the will and the funding to beat back “the world’s most diabolical virus.”

What you don’t see can hurt your cat…and you too

This is the second of 16 student posts, guest-authored by Eileen Ball.

The beauty of dogs and cats as companions is that we don’t have to raise them to go out into the world and be successful.  As pet parents we can set the household “rules” according to what works for us and get on with enjoying our pets; hopefully for many years.   According 2011-2012 APPA National Pet Owners Survey cats have now surpassed dogs as the most common household pets in the United States.  Despite this fact  the same survey reports that in 2010 only 30% of US veterinary patients were cats.  As a companion animal veterinarian I find these statistics alarming and I fear that many well-intentioned pet owners are simply unaware of the risks that can accompany the joys of cat ownership.

A common perception is that indoor cats don’t need veterinary care.  In this sentence there two big factors that need to be addressed.  The first, and for me the most obvious, is that indoor cats need veterinary care too!  In a bit I’ll get to explaining that even without outdoor threats,  such as motor vehicles and big dogs, indoor cats and their owners face almost as many dangers as their outdoor brethren.    The other part of the eleven word sentence at the start of this paragraph that requires definition is the concept of “indoor cat.”    During my ten years as a practicing veterinarian I had many a conversation with an owner that started with the question “Is Fluffy indoor or outdoor?”  Followed by the owner confidently responding “indoor.”  As we moved forward in our discussion and I asked more about how Fluffy spent her day I’d often learn that Fluffy had access to the yard or deck and often spent long periods of time there.  There were alternative versions of the discussion where Fluffy didn’t physically go outside but the dog did as well as scenarios where mice, birds or bats came indoors even though they weren’t invited.  The reality is that In order for a cat to be considered 100%  indoor it would need to live in a biosphere.

So why should you take your indoor cat to the veterinarian on at least a yearly basis?   The first and most important reason is that your cat has the potential to carry parasites and diseases that can be transmitted to you and your family.  These include but are not limited to:  hookworms, roundworms, fleas, ticks, ringworm and Rabies.  According to the CDC approximately 14% of the US population has been infected with a type of roundworm called Toxocara.  Indoor cats are a potential source of exposure as they generally use litter boxes and they frequently contact surfaces such as countertops, bathroom vanities, kitchen tables and bedding.  Many cat owners have the misunderstanding that because their cats do not go outdoors they are not at risk.  This is simply not true.  There are lots of indoor/outdoor parasite sources such as mice, rats, other pets and people.  Hookworm and roundworm infections are easily and safely prevented with a variety of medications.  Your veterinarian can run a simple fecal test to see if your cat is infected with these or other parasites.  Another concern for cat owners is the transmission of a type of bacteria called Bartonella.   In most cases infected cats will show no symptoms, although in some it may cause gum disease, conjunctivitis (swollen membranes around the eyes) or respiratory disease.  Bartonella can spread from cats to humans.  It is the causative agent of Cat Scratch Disease in people.  Cats often get this bacteria from fleas and they can transmit it to humans via bites and scratches.  While parasites and Bartonella are a significant risk for healthy humans in those who don’t have a fully functioning immune system the risk is magnified even further.

The most important disease that you can protect your indoor cat from is Rabies.  This is a virus that is spread via saliva and is almost always deadly.  Rabies infection is common in skunks, raccoons, foxes and bats.  A bat getting into the house through an open window or a chimney is a very real risk for any animal or person in your house.  If you should happen to find a bat in the house with your cat (or other pets) you must assume that they were bitten.  Because of the thick fur that cats have it can be impossible to see a small bite wound.  Depending on local laws you may be required to vaccinate your cat for Rabies every 1-3 years.

There are other conditions such as ringworm and toxoplasmosis that cats can have without showing any signs.  People with healthy immune systems are not likely to show symptoms if they are exposed to these parasites but for others with HIV, cancer, pregnancy or a suppressed immune system serious consequences can occur.  When I think of ringworm without symptoms I always recall one of my patients, Miss Kitty, who was loved and adored by her entire family.  Miss Kitty and her humans were originally from Hawaii and had moved to Virginia where I was in practice.  Since Miss Kitty couldn’t travel from mainland US to Hawaii without quarantine the relatives in Hawaii decided to come to Virginia for Christmas.  Miss Kitty’s human grandmother happened to have breast cancer and was undergoing radiation.  The family had a great holiday.  Shortly after her return to Hawaii the grandmother developed circular, itchy scabs on her skin.  Her MD diagnosed it as ringworm and asked if she had any pets.  The grandmother said “no” and the MD presumed she had picked it up from the environment and started treating her.  It was a couple months later in conversation with Miss Kitty’s owner that I’d inquired about the holiday visit and the grandmother’s health.  Miss Kitty’s owner described the wonderful time that they’d had and mentioned that the grandmother had enjoyed the trip except for her persistent skin lesions.  A bell went off in my head and I decided to test Miss Kitty’s hair for ringworm.  Sure enough even though she’d never had a problem with her skin Miss Kitty was positive for ringworm.  Based on the species we cultured the grandmother’s MD was able to change treatment and get her skin cleared up quickly.

Finally, as most people who have shared their lives with both dogs and cats will agree, cats are not small dogs.  While the process of domestication for both dogs and cats has been ongoing for thousands of years it is estimated that the dog started the process 9-10,000 years before the cat.  For this reason cats tend to display a “survival of the fittest” instinct that we don’t see in dogs. Because of this instinct cats generally aren’t transparent when they don’t feel well.  Some cats are prone to chronic heart, thyroid  and kidney diseases that can often be detected with a thorough examination and some bloodwork.  Although most of these chronic conditions can’t be cured, with good veterinary guidance they can be well managed and allow you to share many happy years with your cat.

If your cat hasn’t been to the veterinarian in awhile I hope you will consider scheduling an appointment.  This can not only make life longer and better for your cat it can also protect you and your family from serious disease.

References:

American Pet Products Association 2011-2012 Pet Owners Survey

http://www.americanpetproducts.org/pubs_survey.asp

http://www.cdc.gov/parasites/toxocariasis/epi.html

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002581/

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002310/

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002411/

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001661/

http://catvets.com/cfpandpractitionersearch/

Bartonella Spp. In Pets and Effect on Human Health,  Chomel et al. Vol. 12 number 3, March 2006,  www.cdc.gov/eid

 

 

 

 

 

 

 

 

 

 

 

 

New site–“History of Vaccines”

This is great. The College of Physicians of Philadelphia has launched a site on The History of Vaccines. I’ve been poking around, and there’s an incredible amount of stuff to check out. They have a nice FAQ, Top 20 questions about vaccination, as well as some great activities (herd immunity! learn about Koch’s postulates! understand the relative risk of vaccination versus other events!) and a metric fuckton of articles and images. Looks to be a fantastic resource for students, and for anyone interested in understanding vaccination.