Veterinary Forum | December 2009 by davidpsu

NEWS WEB EXCLUSIVE: AVMA UPDATES H1N1 RESOURCES FOR VETERINARIANS, OWNERS

FORUM

REAL PRACTICE. REAL MEDICINE. REAL NEWS.

re c re eive gi th st e er d fo igi r F ta RE l e W E a dit e’ t ion GR ve , EE Go N! ne

DECEMBER 2009 • VOL. 26, NO. 12

veterinary

With the introduction of the first vaccine for canine influenza,

only the love is contagious. Now you can provide your patients with more comprehensive protection against respiratory infection. Love is not the only thing in the air. Canine influenza virus (CIV) has been confirmed in dogs across 30 states and the District of Columbia, and its prevalence is rising.1 And because most dogs are naive to the virus, virtually every naive dog exposed will become infected.2 CIV is highly contagious and sometimes deadly. Clinical signs associated with CIV can be confused with kennel cough making accurate diagnosis difficult. Now you can broaden the respiratory protection you currently offer to patients with the addition of the first vaccine for canine flu, Canine Influenza Vaccine, H3N8. Canine Influenza Vaccine, H3N8 —a killed virus vaccine from Intervet/Schering-Plough Animal Health—significantly decreases clinical signs of disease and reduces viral shedding, and its safety has been confirmed in a study involving more than 700 dogs.3

Notice: This product license is conditional. As with all USDA conditionally licensed products, data submitted to the USDA supports a reasonable expectation of efficacy. Safety was established in trials involving more than 700 dogs.

So while CIV, like love, can be easily spread and hard to identify, it no longer has to be so overwhelming. To learn more, contact your Intervet/Schering-Plough Animal Health representative, visit www.doginfluenza.com, or call our technical services team at 800-224-5318.

References: 1. Syndromic surveillance data of Cynda Crawford, DVM, PhD, University of Florida, and Edward Dubovi, PhD, Cornell University. 2. Key facts about canine influenza. CDC Website. Available at: http://www.cdc. gov/flu/canine. Accessed May 1, 2009. 3. Data on file, Intervet/Schering-Plough Animal Health. Copyright © 2009 Intervet International B.V. All rights reserved. SPAH-VC-284:9412

® EDITORIAL STAFF DECEMBER 2009

contents

Tracey L. Giannouris, MA, Executive Editor

2 FEATURE STORY

267-685-2447 | tgiannouris@vetlearn.com

What’s the future of the veterinary pharmacy?

Paul Basilio, Associate Editor

Lowell Ackerman, DVM, DACVD, MBA, MPA

Allyson Corcoran, Editorial Assistant

Shoring up the veterinary pharmacy in the Internet age.

Dorothy Normile, VMD, Chief Medical Officer

Parasite 101

VETERINARY ADVISER

Infection with the Canid Heartworm: Public Health Considerations............... 18 Dr. Jerold H. Theis

Issues in Practice Mindset or mental meltdown? ............ 25

SALES AND MARKETING Tom McCabe, Vice President, Business Development 267-685-2662 | tmccabe@vetlearn.com

Dr. Thomas E. Catanzaro

also in this issue

DESIGN

Advertisers Index ...............................14

Michelle Taylor, Senior Art Director

Market Showcase ..............................29

David Beagin, Art Director

Classiﬁed Advertising ........................31

Bethany Wakeley, Production Artist Stephaney Weber, Production Artist

Christine Polcino, Traffic Manager WEB-EXCLUSIVE FEATURES: vetlearn.com

NEWS

■

Cat infected with H1N1 dies

■

AVMA updates H1N1 resources for veterinarians, owners

Banﬁeld sponsors Season of Suppers

■

Bulldog wins ﬁrst VPI Hambone Award

■

Eukanuba Breeder Symposium

■

PetSmart Expands Recall on Pet Carousel, Inc. Products

■

LSU alumni travel to Liberia for the Veterinarians without Borders program

■

Colorado and FWS protect black-footed ferret

■

CUSTOMER SERVICE 800-426-9119, option 2 | info@vetlearn.com PUBLISHED BY

780 Township Line Road • Yardley, PA 19067 PRESIDENT Derrick Kraemer

Study looks at animal fostering beneﬁts in older people

Vetlearn.com | December 2009 | Veterinary Forum

Veterinary Forum (ISSN 1047-6326) is published monthly by Veterinary Learning Systems, a division of MediMedia USA, 780 Township Line Road, Yardley, PA 19067. Periodicals postage paid at Morrisville, PA, and additional mailing offices. POSTMASTER: All rights reserved. Reproduction in whole or in part without permission is prohibited. Copyright ©2009 Veterinary Learning Systems.

What’s the future of the veterinary pharmacy? Lowell Ackerman, DVM, DACVD, MBA, MPA Special to VETERINARY FORUM

Veterinary medicine is not recession proof,1 but it is resilient and has fared better than many other industries that rely on the public’s discretionary income. However, the industry is vulnerable in a few key areas, including the pharmacy. The pharmacy has long been a solid profit center for veterinary practices, and according to AAHA’s Financial & Productivity Pulsepoints, Fifth Edition, pharmacy income averages 18.9% of total hospital income, with food sales representing an additional 4.9%.2 Add to that potential over-the-counter retail sales (including parasiticides, shampoos, flea combs) that AAHA reports as an additional 6.1% of total hospital income, and product sales account for more than 25% of hospital revenue. How secure is your pharmacy revenue stream in the era of Internet pharmacies, inexpensive human generics, ©Lowell Ackerman DVM, DACVD, MBA, MPA

Veterinary Forum | December 2009 | Vetlearn.com

big box retailers and other companies competing with veterinarians for pet-owner dollars? Clients have more options than before when choosing medications for their pets, and it is time for veterinarians to consider how to best use their pharmacies and compete in a crowded marketplace.

Do we need to change? For many decades, veterinarians have had a relative monopoly on the sale of prescription pet medications, and this has been an enduring boon for many practices.

Are you treating the right bug? ®

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Effectively treating canine respiratory disease can be tricky when you’re guessing which infectious agent is involved, and whether or not a co-infection is present. With test results available in just 1-3 days, FastPanel® PCR profiles help you pinpoint the underlying cause of disease more quickly and make betterinformed treatment decisions.

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A perfect ﬁt...

no matter what BOEHRINGER INGELHEIM VETMEDICA, INC. (BIVI), has invested in the long-term growth of its animal health business by acquiring select Fort Dodge Animal Health products. That means our product portfolio in the pet, equine and cattle markets has grown. And that BIVI’s already substantial investment in developing innovative animal health products has increased signiﬁcantly. What hasn’t changed is our commitment to understanding our customers’ needs. While we are making some changes here at BIVI, we assure you we are taking the necessary steps to make sure your business is not interrupted.

No matter what, we’ve got you covered.

coat you wear. For questions or concerns, please contact your local BIVI representative or visit WWW.BI-VETMEDICA.COM. For customer service or to ďŹ nd your local BIVI representative, call 1-800-325-9167. For technical product information, contact

1-866-638-2226.

Examples of Human Generic Medications Commonly Dispensed by Veterinarians* Amoxicillin

Doxycycline

Metoclopramide

Cephalexin

Enalapril

Metronidazole

Ciproﬂoxacin

Furosemide

Prednisone

Digoxin

Meloxicam

Thyroxine

*FDA CVM Green Book online. Accessed: Oct. 27, 2009.

However, while many clinics have priced pet food relatively competitively after realizing that pet owners would likely comparison shop, most practices continue to price their prescription drugs the same way for years. Veterinarians may worry about Internet pharmacies and advertising that entices some clients to ask for prescriptions and shop elsewhere, but this is only the beginning. We have not yet reached the “tipping point” at which clients will routinely look elsewhere for pet medications. As clients become aware of alternative channels for acquiring veterinary medications, they will realize that Internet and big box retailers now sell some of the most popular pet medications and that veterinarians frequently dispense human generic drugs that are much less expensive — and, in some cases, free — elsewhere. When a client brings a pet in for an examination, he or she is prepared to pay professional fees for veterinary expertise in medical care, diagnostic testing and treatment recommendations. After all, veterinarians deserve proper compensation for the high level of skill they offer. However, after the veterinarian recommends a treat-

ment, the professional part of the visit concludes, and the client is free to purchase the recommended products from any business that offers the best combination of price and convenience. Most clients will pay a slight premium to purchase the medication in the veterinary office, but medication is often considered a commodity and not something to which professional fees should be attached. For example, is the cephalexin that you dispense superior to the cephalexin available at a retail pharmacy? Is the flea control product that you sell different than the identical product available at retail outlets or on the Internet? Clients will not begrudge spending more at a veterinary office than at a retail outlet for a similar product — within reason. Clients may perceive that it is more convenient to purchase a product at the veterinarian’s office, but when this convenience is coupled with counseling from staff on the product’s proper use, the client may recognize the added value to the purchase. However, if there is a large discrepancy between a practice’s prices and a retailer’s, owners may be concerned that prices for services at the practice might be inflated as well. This is not the type of message a practice wants to convey, considering that veterinary services are a relative bargain for pet owners compared with human medicine.

Human generic medications Human generic medications are tested for equivalency against branded human medications. Most of the human generics that veterinarians stock, which are not FDA-approved for use in animals, may come in inconvenient dose sizes for animals and may have directions

Pricing for Generic Medications at Various Outlets* Outlet

Price

Offering

Walmart

30-day supply on more than 360 generic drugs; 90-day supply for $10

Target

30-day supply on more than 300 generic drugs

Kmart

30-day supply on selected generic drugs; $10–$15 for 90-day supply of 500 generic drugs

Walgreens

$12.99

90-day supply on more than 300 generic drugs

Publix

Free

14-day supply of selected antibiotics, plus reﬁlls

Meijer

Free

14-day supply of selected antibiotics, plus reﬁlls

Hannaford

30-day supply on selected generic drugs

Sweetbay

30-day supply on more than 400 generic drugs

Wegmans

$11.99

90-day supply on selected generic drugs

*Not all offerings are available at all geographic locations. Prices veriﬁed online as of Oct. 27, 2009.

Veterinary Forum | December 2009 | Vetlearn.com

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and cautions that are inappropriate for animals. From a business standpoint, these products are the same or similar to those sold by pharmacies, department stores and other retailers, often for considerably less cost. Retailers are locked in a bitter battle for customers and, in some instances, have reduced the price of many human generic drugs to a few dollars for a month’s supply. Some retailers even provide these products — including prescriptions for pets — at no cost to the consumer. Realistically, there are only a few options for dispensing human generics, none of which is very profitable. You may be able to sell the product for less than the branded medications that you carry, but there is no way that you can sell them as inexpensively as lowprice retailers and still make a profit. What do you tell clients who ask about the difference between the human generic that you offer and the less expensive human generics available elsewhere? Even if veterinary practices drop dispensing charges, it is still impossible to offer human generics at a competitive price without losing money. The other option is to continue selling human generics and hope that clients do not notice that the same products are available elsewhere at significantly lower prices, despite the millions of dollars that retailers spend to promote their bargains. Pet owners are being conditioned to expect that human generics are the treatments of choice for many animal ailments — likely an unintended endorsement by the veterinarians dispensing them. This does not mean that human generics do not have value. If the goal is to deliver medications to owners at fair and competitive prices and you believe that administration of a human generic is in a patient’s best interest, then the sensible solution seems to be to write prescriptions for these products and allow owners to find the best bargain. When the profitability of selling human generics is analyzed, the drugs only remain profitable at current veterinary pricing as long as clients are unaware of the alternatives. This is not a sustainable business model. In addition, profits tend to be marginal at best when markups are applied to inexpensive medications. If a human generic costs you a few pennies each and you triple that to arrive at a retail price, you still have a very meager return for something the client could have purchased elsewhere for less money. From a business perspective, it makes the most sense to stock veterinary-labeled products for sale and price them appropriately (more on that later). These veterinary-labeled products are FDA-approved, tested in

MC09592n

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Veterinary Forum | December 2009 | Vetlearn.com

5/15/09 11:47:59 AM

I am more than just a cat.

I am an

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Iams® ProActive Health — Now with Prebiotics TM

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problems or adverse events. This should be a compelling argument. After all, what have human generics companies done for you lately?

Pet Med Express Revenue 2001â&#x20AC;&#x201C;2008 (In $ Millions, rounded)* $200

$188

$180 $162

Revenue (in millions)

$160 $138

$140 $120

$108 $94

$100 $80 $55

$60 $40 $20

$32 $10

$0 2001

2002

2003

2004

2005

2006

2007

2008

*From www.1800petmeds.com

Figure 1.

animals for safety and efficacy, come in formulations that are convenient for the species you are treating and are manufactured by companies that support the veterinary industry and stand behind their products if there are

Not All Kittens are Born Cuddly. Feral kitten socialization information available at alleycat.org/Kittens.

What about Internet pharmacies? Most veterinary practices are concerned about Internet pharmacies, but these companies are only exploiting the sometimes unrealistic drug pricing models used by some veterinarians. Veterinarians may be surprised to learn that most veterinary pharmaceutical manufacturers do not sell products directly to Internet pharmacies. Often, non-veterinary Internet pharmacies purchase products from veterinarians who are often referred to as diverters and who purchase the products from manufacturers or distributors. New pharmacy licensing requirements require wholesale drug distributors that know or suspect that prescription drugs are being diverted to report their suspicions to the licensing agency,3 but for now, this practice still appears to be commonplace as evidenced by ongoing sales of these products through non-veterinary channels. It is interesting that even after diverters are paid a commission for buying these products for Internet pharmacies, the pharmacies are still able to sell the products for less than veterinarians who price according to standard markups. This is because Internet pharmacies sell commodities based on a retail competitive pricing model, while some veterinarians continue to try to price products as if they were professional services. If veterinarians adopted a more retail-friendly pricing model, Internet pharmacies would likely cease to be much of a threat because they compete based mostly on price and, to a much lesser extent, on convenience. Internet pharmacies also have inherent expenses associated with shipping and handling and paying commissions to acquire diverted products. Veterinarians have yet to heed the warnings, and Internet pharmacies have done quite well at the expense of veterinary practices, even in a tough economy (Figure 1). What are the alternatives? To operate a pharmacy as an efficient profit center, veterinarians need to manage inventory and price products appropriately. There are very real costs associated with inventory, such as the direct cost of acquisition, which is the price paid for the medication itself, and indirect costs associated with ordering and stocking products. The indirect costs can constitute 20% to 45% of the acquisition price, depending on how efficiently the pharmacy is managed.

W W W. A L L E Y C AT. O R G

10 Veterinary Forum | December 2009 | vetlearn.com Education â&#x20AC;˘ Advocacy â&#x20AC;˘ Action

Veterinary Forum | December 2009 | Vetlearn.com

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Call 800.999.0297 or visit www.summitvetpharm.com today. PROTECTS AGAINST: FLEAS | FLEA EGGS | FLEA LARVAE | FLEA PUPAE | DIVERSION | COUNTERFEITS ©2009 Summit VetPharm LLC, Rutherford, NJ 07070 Vectra, Vectra 3D and Bloodhound are registered trademarks and Vectra for Dogs & Puppies is a trademark of Summit VetPharm LLC.

9062 VDP Launch 8x10.75.indd 1

11/5/09 11:26:42 AM

The Relation of Margins and Markups to Retail Price Product Cost Margin

Retail Price

Markup

Acquisition Cost

Figure 2. Markups tend to inďŹ&#x201A;ate the cost of expensive drugs. As drug price increases and markups are applied, retail prices climb much faster compared with acquisition costs. Margins provide full-cost recovery and more gradual price escalation.

The most challenging issues regarding pharmacy vulnerability involve pricing models, which can be complicated by the tendency to pay associates professional

commissions on pharmaceutical sales. The three basic pricing models used in veterinary practices today are markup, margin and community pricing. Markups are the most common. It is not unusual for veterinary hospitals to use markups of 100% to 200% to arrive at a retail price. This is the result of doubling or tripling the acquisition cost of medications and adding a dispensing fee. The magnitude of markup is extreme by retail standards, and paying a professional commission on pharmaceutical sales only compounds the problem of trying to close the gap between veterinary prices and those of competitors. Markups have another unfortunate consequence: they tend to amplify the costs of expensive medications or treatments intended for large dogs and minimize the costs of inexpensive medications or treatments intended for small dogs or cats. For example, if a practice doubles the price of a $0.10 tablet, it has $0.20 of revenue per tablet and $0.10 of direct cost. If the practice doubles the price of a $10 tablet, it has $20 of revenue per tablet and $10 of direct cost. Does this make any sense? Consider the administration of an injectable antibiotic that costs $1/lb of body weight at a clinic that typically doubles costs to arrive at a retail price. If the injectable is used in a 10-lb cat and the practice charges $20, the drug cost is $10, and $10 is left to cover all indirect costs and commissions and to provide a profit. The client would have likely been prepared to pay much more for the convenience of not having to pill his or her cat. However, if the practice charges $200 to treat a 100lb dog with the same injectable, the drug cost is $100, and $100 is left to cover all indirect costs and commissions and to provide a profit. The client would not likely be as happy as the cat owner. After the cost of the drug was covered, did the practice need to charge 10 times as much for injecting the dog, compared with the cat? The cat owner obviously received a much better deal. For practices that see the inequality in the markup model, margin or cost-plus models are good alternatives. Veterinarians already use this premise on a simple level when selling pet food. They implicitly realize that the cost of a bag of pet food cannot be doubled or tripled without a lot of tough questions from pet owners. Often, clinics apply a unit price to each item rather than a markup formula or use a much lower markup than that used for pharmaceuticals. In addition, practices rarely pay professional commissions on the sale of pet foods because the prices would not be kept competitive. (continued on page 15)

Veterinary Forum | December 2009 | Vetlearn.com

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Advantage Multi® for Dogs (imidacloprid + moxidectin) Topical Solution CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. WARNINGS: For the ﬁrst 30 minutes after application: Ensure that dogs cannot lick the product from application sites on themselves or other treated dogs, and separate treated dogs from one another and from other pets to reduce the risk of accidental ingestion. Ingestion of this product by dogs may cause serious adverse reactions including depression, salivation, dilated pupils, incoordination, panting and generalized muscle tremors. In avermectin sensitive dogs, the signs may be more severe and may include coma and death. CONTRAINDICATIONS: Do not administer the product orally. Do not use this product (containing 2.5% moxidectin) on cats. HUMAN WARNINGS: Children should not come in contact with the application site for two (2) hours after application. See Page 12 for Product Information Summary

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AM09885

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News Bite

Internet Popularity Among Pet Owners a Big Plus Packaged Facts estimates that the Internet is the fastest growing sales venue for pet products in the United States, with sales expected to surpass $1 billion by 2012. More marketers and retailers are using the medium, and pet owners are more likely to shop via the Internet and rely on it for information. This is especially good news for “info-centric” health products, which are already heavily represented on the Internet, reﬂecting the grass-roots origins of many such products as well as the ability of the Internet to communicate product beneﬁts with detailed information. The Internet is also important because it hosts a virtual community of pet devotees who exchange pet product ideas and product tips through Web sites, chat groups, blogs, and e-mail.

advertisers index Want Free Information About Our Advertisers’ Products and Services? Send an email to productinfo@ForumVet.com. AAHA AAHA Long Beach 2010 .....................24 Alley Cat Allies Feral Kitten Socialization .....................10 Andis Lightspeed Clipper ..............................19 Animal Health Options ProMotion ...........................................21 Antech Diagnostics FastPanel PCR ......................................3 Banfield, The Pet Hospital Career Opportunities ...........................26 Bayer HealthCare, Animal Health Advantage Multi for Dogs ....................13 resQ......................................................8 Boehringer Ingelheim Vetmedica, Inc. New Product Portfolio ....................... 4–5 ProZinc ....................................... Cover 3 Companion Animal Hyperbarics Veterinary Hyperbaric Solutions ............................................15 Dentalaire Bio-Ray SDX Digital Dental X-Ray System......................................20 Iams ProActive Health ...................................9

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The VETERINARY FORUM Advertisers Index is provided as a service to our readers. The publisher does not assume responsibility for any errors or omissions. Listed companies advertise products and services in this issue.

Veterinary Forum | December 2009 | vetlearn.com

(continued from page 12)

A similar approach can be taken with pharmaceuticals, such as tablets, capsules, liquids, shampoos and injectables. The approach can be profitable for the practice and fair to clients, regardless of the size of their pets or the cost of the medications. This approach involves adding a margin or base amount to products or services that does not vary with the cost of the drug or the size of the animal. Margin pricing involves taking the actual unit cost of the drug and adding an acceptable amount to cover indirect inventory costs of ordering, storage and loss. This indirect inventory cost can be expressed either as a fixed amount or as a percentage of actual product cost. At this point, there is full cost recovery of all direct and indirect costs, but no profit. A unit or margin charge is then added and represents what the practice wants to earn for each unit dispensed or administered. This allows the practice to make a standard margin on every product sold while covering acquisition and inventory costs (Figure 2). With this method, there is no penalty for a pet that requires a more expensive medication. The practice makes relatively more on less expensive medications, which are less likely to be price-shopped, and relatively less on expensive medications, but with the same net profit regardless of the product. This allows veterinarians to select the product that would be most appropriate for the pet without worrying about loss of profitability for the practice. It is possible to pay commission to associates on the basis of margins, but only on the margin amount itself and not the full retail price, since all but the margin represents expense, not profit. Community pricing is a way of establishing a selling price on the basis of what others are charging. A practice might set the community price based on the pricing used by other veterinary hospitals in the area, retail prices, Internet pharmacies or other outlets. Community pricing ensures that you will not be readily undersold; however, unless costs are determined, you may still be stocking and dispensing medications that are not profitable for the hospital. As demonstrated above, it is not possible for veterinarians to run a profitable, sustainable pharmacy by selling products that can be purchased elsewhere at lower prices. Retail pharmacies often sell human generics as “loss leaders” to attract customers to the store so they will buy other products. In this way, the drugs represent a marketing expenditure and are not meant to be profitable. Other pharmacies embark on community-pricing initiatives to avoid losing customers to retailers offering

Vetlearn.com | December 2009 | Veterinary Forum

discounts. This is one important reason why veterinarians should not compete with pharmacies by selling human generics.

The importance of customer service It is important for veterinarians not to judge a client’s desire to save money as disloyalty to the practice. After all, when a client receives a prescription from his or her physician, he or she may compare prices at different pharmacies, including online and foreign pharmacies. Clients pay professional fees to the veterinarian for medical advice. As far as they are concerned, the purchase of the medication is just a commodity transaction. It likely has nothing to do with how they feel about the medical care the pet received, and many are shocked to see veterinarians react in a threatened manner when asked if the same or equivalent medication might be available online or at a retailer. Do not be threatened or respond defensively because this would be an overreaction to an honest question and could adversely affect the client’s perception of you as a pet health advocate. Your goals should be to select the most appropriate medication for the patient, to make a reasonable profit

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”

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Easy to set up and easy to use, Vetstreet® is a powerful practice communication and management tool that keeps you in touch with your clients via Pet Portals. To discover how Vetstreet can help you increase client satisfaction, build compliance, and enhance your bottom line, visit Vetstreet.com, call toll-free 888-799-8387, or email info@vetstreet.com.

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on stocking and dispensing appropriate medications and for clients to receive value for pharmaceutical purchases, medical services and counseling. These goals may require changes to the current pharmaceutical pricing models used by veterinary practices, adjustments to professional production compensation for associates, preferential stocking of products labeled for use in particular species, appropriate communication about benefits and risks of all medications dispensed and serving as an advocate for the needs of clients and pets. Additional considerations include the following:

...with Vetstreet

• Educate clients about pet insurance to help them afford needed medications • Provide your own Web-based pharmacy if clients find this convenient • Remind clients to administer medications on schedule, especially those that are periodically administered, such as heartworm and flea-control products • When medically prudent, use injectables to improve compliance and convenience • Maintain a practice formulary to keep inventory lean and avoid duplication • Monitor product turnover and stock products according to need and use • Expect professional compensation for professional services and retail revenue for commodity transactions

Summary The veterinary pharmacy is at an important cross roads, and veterinarians will ultimately determine whether it remains an important profit center or continues to be eroded by outside competition. Success is predicated on veterinarians acting in their best interest and stocking competitively priced, veterinary-labeled products rather than human generics. New models and approaches need to be considered for the profession. Will veterinarians heed the call to action? vF References: 1. Ackerman L. Blackwell’s Five-Minute Veterinary Practice Management Consult. Ames, IA: Blackwell Publishing; 2007. 2. American Animal Hospital Association. Financial & Productivity Pulsepoints, 5th ed. Lakewood, CO: AAHA Press; 2008. 3. Lust E. How changes affecting wholesale drug distribution can impact veterinary practitioners. JAVMA. 2008;233(7):1081-1082.

Dr. Ackerman is the author of Blackwell’s Five-Minute Veterinary Practice Management Consult, a specialty hospital services liaison for Pﬁzer Animal Health and a clinical professor at Tufts University Cummings School of Veterinary Medicine.

Vetlearn.com | December 2009 | Veterinary Forum

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PARASITE 101

Infection With the Canid Heartworm: Public Health Considerations By Jerold H. Theis, DVM, PhD The Companion Animal Parasite Council (CAPC) focuses on the prevention, control, and treatment of parasitic diseases in pets, with a particular emphasis on heartworm disease and endoparasites of zoonotic concern. Although the dog remains the primary host for heartworms, recently, the awareness of heartworm disease in cats has greatly increased. Whether Dirofilaria immitis infection has zoonotic potential has been questioned, with no real indication of the actual incidence of zoonotic disease. This article describes several cases of human pulmonary disease shown to be caused by D. immitis infection. Although uncommon, the disease occurs with sufficient frequency to be considered in the differential diagnosis of isolated pulmonary nodules. Given these findings and the fact that heartworm disease exists in all 50 states and can be spread by a multitude of mosquito species, it is likely that a large number of humans are exposed to heartworms. As a result, a percentage become infected. This article questions whether D. immitis infection has zoonotic potential. Furthermore, the emerging data suggest a need for improved vector control. Michael Paul, DVM Executive Director, CAPC The filarial nematode Dirofilaria immitis is geographically cosmopolitan, existing in varying degrees throughout the temperate, subtropical, and tropical latitudes in both hemispheres.1–5 Depending on geographic area, its requisite host community consists of different species of mosquito, which serve as intermediate hosts,2,4,6–10 and members of the genus Canis (e.g., Canis familiaris [domestic dog],1–5,11–15 Canis latrans [coyote],16–20 Canis lupus [grey wolf],21 Canis rufus [red wolf]22–24), which serve as definitive hosts.

Epidemiology of Human Exposure It is logical to assume that human exposure to infective, third-stage larvae of D. immitis is the result of spillover from infective mosquitoes that acquired the organism from feeding on infected, microfilaremic definitive hosts. The rate of spillover is a function of the density of infected canids and infective mosquitoes as well as human exposure to those mosquitoes. Data analyzed from crude surveys of veterinary clinics in the United States, conducted under the auspices of the American Heartworm Society, suggest that there are four levels of

Veterinary Forum | December 2009 | Vetlearn.com

infection in the US domestic dog population, each of which differs by order of magnitude from the next higher level.24 When the numbers of reported US cases of human dirofilariasis involving the lungs are categorized according to states reporting canine infections, the greatest numbers of reported human cases are in states with the largest numbers of reported canine infections.24 However, the totals for human cases are cumulative, spanning a 60-year period, whereas the reported canine cases are for a single year (2001).24 Clearly, there are insufficient data to show that the risk of human infection with D. immitis is proportional to the level of infection in dogs. There are no credible population data on the numbers of dogs per household for any area of the United States.25–31 Therefore, the canine density cannot be compared between different communities with any reliability. There are no nationwide surveillance programs for canine D. immitis infections. Therefore, it is not known whether canine infections are increasing, decreasing, or remaining constant in any given geographic area.32 No incidence studies on client-owned dogs are being conducted on a continuing basis to provide information on changes in the infection rate, if any, in the canine population. With all these unknowns, it is not possible to say with any accuracy that the risk of human infection with D. immitis is greater in Texas, for example, than it is in Tennessee, Indiana, or New England. Each of the latter three areas has had four reported human cases of pulmonary dirofilariasis over the past 43 years, whereas Texas has had 23 cases.24 Practitioners are not consistent in writing up single-case studies, and medical journals do not consistently publish such papers. Therefore, the numbers of reported human cases from any one area do not necessarily reflect the actual numbers of humans diagnosed, let alone infected, with D. immitis.

Public Health Significance for Humans The vast majority of reported and proven D. immitis infections in humans have involved the lungs.24 The typical radiographic finding is a “coin lesion,” a 1- to 4-cm spherical opacity in any lobe of the lung.24 However, this lesion is also produced by at least 20 other pathologic conditions,

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peer reviewed including malignant tumors, metastatic tumors, benign tumors, cysts, and inflammatory granulomas.33 Most of the published cases of human pulmonary dirofilariasis were reported to be asymptomatic and were discovered on routine chest radiography.24 Based on the number of published cases, most physicians believe that the disease is rare. However, the human medical profession can harbor various misconceptions about the life cycle and host–parasite relationships of D. immitis.24 From the published articles on human cases, there appears to be little understanding regarding the following: • The actual means whereby infectious larvae are transferred from vector to the vertebrate host • D. immitis is a vascular-dwelling nematode and does not live in the heart • The adult worm has been found in arterial branches all over the dog’s body, not only in the pulmonary artery24 Such systemic arterial infections in the dog result in paralysis, paresthesia, incoordination, brain infections, and blindness. In humans, this helminth has also been reported in arteries other than the pulmonary arteries.34–38 This raises the possibility of thrombosis of arteries in the human brain, leading to significant, long-term debilitation. If such an event occurs, it is very unlikely that the cause of the stroke would be discovered because it is unacceptable to take appropriate diagnostic samples from a survivor, and autopsies are rare in individuals who die with a diagnosis of stroke. At present, the demonstrated public health significance of pulmonary dirofilariasis is the cost of health care delivery in the differential diagnosis of the coin lesion (approximately $80,000 to $100,000 per case) and the anxiety that this lesion may produce in patients because of the possibility of lung cancer.31

Evaluating Exposure Risk to Humans It would be very helpful to determine the number of people who become infected with D. immitis. Because of the mechanism of transmission of infective larvae, it is entirely possible that the infection rate in humans is low.39,40 However, all filarial helminths that are spread from vectors to humans are transmitted in the same fashion. The infective larvae break out of the labium and labellae of the vector and are deposited on the skin surface, along with a pool of hemolymph from the vector. The infective larvae must

Veterinary Forum | December 2009 | Vetlearn.com

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PARASITE 101

then make their way into the skin via the hole that is left when the vector is finished feeding.39,40 Despite this inefficient means of transmission, millions are infected with human filarial helminths all over the world.41 Thousands of infective larvae may infect a human in a single year — at least in the case of onchocerciasis — but only a few will develop to the adult stage.42 Infection with third-stage larvae of D. immitis also does not equate with successful development of the worms. Kume and Itagaki43 found D. immitis larvae encased in granulomatous reactions in the subcutaneous tissues of dogs used for their studies on the life cycle of D. immitis. There is no reason not to believe that this same response to D. immitis infective larvae could occur in humans. Under these circumstances, even if the larvae entered a human, they would not necessarily survive to develop to the stage at which invasion of the vascular system normally takes place.43 However, even abbreviated infections in humans could result in sufficient antigen exposure to stimulate antibody production for testing. A third-stage larvae antigen could be used to detect infection in humans for epidemiologic studies,44–46 and an adult D. immitis–derived antigen could serve to evaluate clinical cases.47

Conclusion Until epidemiologic data are derived from examining the sera of asymptomatic humans using a standardized test for detecting antibodies to infective larval stages of D. immitis, infection levels in humans will not be known. The number of published clinical cases could be misleading, as infection does not always lead to recognized disease with this filarial nematode, and the pulmonary artery is not the only artery that may be involved in human infections. Veterinarians would do well to monitor these emerging data so they can provide current information for clients who are concerned about the risks of the mosquito-borne parasites that infect their pets. vF Dr. Theis is a professor of medical microbiology at the University of California, Davis, School of Medicine.

To see the references for this article, go to Vetlearn.com

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IN PRACTICE By Thomas E. Catanzaro, DVM, MHA, FACHE, Diplomate, American College of Healthcare Executives

BUSINESS SKILLS

Mindset or mental meltdown? Understanding why you react is one of the keys to effective leadership. I recently received an e-mail that made me angry. It was from a company that I had been talking to for 2 months to resolve a problematic computer purchase. Although I had written repeatedly asking for the correction of certain hardware and software shortcomings, which were costing me time and money, I still felt as if I was getting nowhere. As with many IT support issues, the company wanted payment up front. However, my problem was with a service and a computer system that I had already paid for, and for which the company had promised a solution on multiple occasions. The company even sent me replacement hardware but had forgotten to load the software that I had prepurchased, and it wanted me to pay the postage to return its mistake. The e-mail made my face turn red and my heart rate rise. At first, I wanted to draft an e-mail to the company’s corporate headquarters, possibly starting a war of words that no one would win. Hours of productive time would be lost on both sides, and no one would be happy in the end. This conflict response is an example of the irrational, nonproductive, mindless behavior that is being examined in the current corporate market. This field of study is called neuroleadership in the current literature. The term was coined by David Rock, author of Quiet Leadership. Neuroscience-based research about leadership is appearing in health care and universities in Australia, Europe, and the United States. Neuroleadership involves teaching executives about their brains to foster awareness of what pushes “hot buttons,” and to show leaders how to control their own neurofunctions. To put it briefly, no one can lead others until he or she can lead himself or herself. The science of neuroleadership focuses on the limbic system and the functions of various chemicals in the brain, such as dopamine and adrenaline, which affect behavior. Neuroleadership aims to help us understand the reward and threat circuitry of the brain and how we react to a perceived threat to our status, autonomy, or sense of fairness. It is interesting to note that salary increases, corporate recognition and praise activate our reward circuitry similar

to the activation experienced by an animal that receives a treat or has captured a meal. It is not a stretch to recognize that staff members may unconsciously feel that micromanagement is a threat to their survival. Micromanaging workers from Generations X or Y has been shown to decrease productivity because their brains signal that their autonomy is being threatened. Most people perform more creatively when heading toward an outcome rather than away from a threat (e.g., a controlling or demanding boss). It has been noted that even a small amount of uncertainty generates an error response in the orbitofrontal cortex of the brain, taking attention away from a person’s goals. Studies have shown that people given an intranasal dose of oxytocin, a hormone that aids in interpersonal bonding, collaborate more with coworkers and are happier at work. Release of the chemical can be stimulated in most people by enhancing social networking and interaction in the workplace. Leaders can create a cohesive workplace culture by using the “carrot,” and leaving out the “stick.” This can be achieved by increasing recognition and reward, introducing flexible work hours and allowing employees more autonomy and networking time to achieve well-defined goals, rather than focusing on time clock–based processes. Knowledge of our minds is a tool of effective leadership. However, training our brains and attitudes is not as easy as it sounds. Leadership skills can be taught and integrated into a personal leadership style, but they require total commitment to change and a focus on clear outcomes and expectations rather than processes — concepts that may be alien to many members of the baby boom generation. vF For more information: Catanzaro T. Building The Successful Veterinary Practice: Leadership Tools, vol. 1. Wiley-Blackwell; 1997. Rock D. Quiet Leadership: Six Steps to Transforming Performance at Work. New York: HarperCollins; 2006. Siegel D. The Mindful Brain: Reflection and Attunement in the Cultivation of Well-Being. New York: WW Norton & Co; 2007.

Dr. Catanzaro, a member of the VETERINARY FORUM Editorial Board, was the first veterinarian to be board certified in Healthcare Management. In 1996, he became a Fellow of the American College of Healthcare Executives (FACHE). He is the CEO of Veterinary Consulting International. Dr. Catanzaro can be reached at info@drtomcat.com.

Vetlearn.com | December 2009 | Veterinary Forum

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We believe in saving the lives of Pets and improving the lives of vets. We believe that you should b ocused on your patient, not your paperwork. We believe that flexible hours make for refreshed doctors. We believe cats aren’ Banfield, believeyou’re in our too veterinarians. he only animals that purr. We believe we’re helping families along with theirAtPets. Wewe believe good to be microWe’ll give you the tools you need to do theor fourth, can managed. We believe in providing more resources, not taking them away. We believe a second opinion, or third, best jobbe possible: fromWe resources modern make yours even stronger. We believe in getting out of the way and letting doctors doctors. believeand you own your caree to a healthyas work/life balance, we We believ We believe you went to vet school for a very furry reason. 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