The COVID-19 crisis continues to alter how veterinary professionals administer patient care. To ensure the safety of their staff and the public, practices have adjusted protocols drastically to help maintain proper social distancing.

For house-call veterinarian Patrick Mahaney, DVM, CVA, CVJ, certified veterinary acupuncturist and president and medical director of 

California Pet Acupuncture and Wellness 

(CPAW) in West Hollywood, CA, that means temporarily limiting wellness visits and addressing only serious health concerns.

In addition, he tells dvm360.com Chief Veterinary Officer Adam Christman, DVM, MBA, he's changing his approach to house calls. “When I go to clients' homes, we are changing up the circumstances, where maybe I’d be in their home, now I’m in their driveway or on the porch." For example, he says he had pregnant a client who requested that he administer care to her pet on the patio to prevent potentially exposing her baby to the virus.

Although Dr. Mahaney says he remains healthy, he will continue to adhere to all the recommended precautions. In addition to the previously mentioned changes, he’s also wearing personal protective equipment during appointments, including googles, a surgical mask and gloves. “This is the new normal…,” he says.

To hear more from Dr. Mahaney, watch the video below.

Videos

California house-call veterinarian Dr. Patrick Mahaney shares some of the changes he’s implemented during the COVID-19 pandemic.


From veterinary house calls to driveway visits

A cat in Belgium has become the third animal to test positive for the novel coronavirus, according to a report late last week in 

. The cat reportedly contracted the virus from its owner, who had recently been to Italy and has herself tested positive for COVID-19.

The cat began showing clinical signs of the virus, including diarrhea, vomiting and difficulty breathing, about a week after its owner became ill, at which time a test of the cat’s feces and vomit revealed traces of the virus. Both the cat and its owner are currently on the mend.

This first case of human-to-cat transmission of COVID-19 has sparked more questions about whether and how pets can become infected with or serve as vectors for the novel coronavirus—and how veterinary professionals should address the issue with concerned clients. For answers, dvm360 spoke with Jane Sykes, PhD, BVSc (Hons), chief veterinary medical officer at the University of California, Davis, School of Veterinary Medicine Veterinary Medical Teaching Hospital and founder of the International Society of Companion Animal Infectious Diseases.

What do you think it means that this cat showed clinical signs of COVID-19 while the dogs that tested positive in Hong Kong did not?

 During the 2003 severe acute respiratory syndrome (SARS) outbreak in Hong Kong, a small number of pet cats tested positive for the virus but none became sick. Ferrets could also become infected and did develop illness. Infection in dogs was not identified, but it is my understanding that widespread testing was not performed in dogs.

SARS-CoV-2, the virus that causes COVID-19, utilizes two receptors to enter human cells: the angiotensin-converting enzyme 2 (ACE-2) receptor and a type II transmembrane serine protease (this is similar to the original SARS virus in the early 2000s). The virus binding site on ACE-2 receptors in cats and ferrets are very similar to those of humans, so it would not be surprising if SARS-CoV-2 binds to ACE-2 receptors in cats and ferrets.

The canine receptor has a lower homology, which might explain why cats could be more susceptible to infection than dogs. However, given the low numbers of dogs and cats reported to be infected with COVID-19, it is impossible to say at this time whether cats are more susceptible to infection or clinical signs of disease. Recent studies in ferrets have shown that they can be infected with SARS-CoV-2 and develop clinical signs of fever, lethargy and cough. Ferrets could also transmit the virus to other, in-contact ferrets.

Does this development change what pet owners with signs of illness should be doing to keep their pets healthy?

he report of an cat infected does not change our recommendations. Currently, we don’t have enough information to know whether cats and dogs have the potential to infect humans. To date, all transmission has been human-to-human, after the initial jump from bats (most likely) to humans. In light of the report about the infected cat, the World Organisation for Animal Health (OIE) updated its 

 to note that although some examples of animal infections have been reported to the OIE, currently there is “no evidence to suggest that animals infected by humans are playing a role in the spread of COVID-19. Human outbreaks are driven by person-to-person contact.”

If dogs and cats can shed the virus, it is possible that the quantity of virus shed is too low for transmission to occur, especially if there are no signs of respiratory disease to create aerosols.

Because other infectious diseases can spread between animals and humans, it remains prudent to always exercise good hygiene when people, especially children and the immunocompromised, are around animals. This includes washing your hands (properly) after touching, feeding or cleaning up after your pet, avoiding rough play (especially between children and animals) and not allowing pets to sleep in bed with immunocompromised people or lick faces, wounds or healthcare devices.

Pet owners who a have tested positive for COVID-19, or those who are highly suspected to have it but have not been tested, additional precautions are warranted. These owners should limit contact—ideally having someone else in the household care for the pet—and wear a face mask. The pet should be quarantined with the owner and any signs of illness reported to their veterinarian.

Critically, we need to inform owners that it is important not to over-react and disconnect from their pets. The importance of the human-animal bond and its positive healthcare effects cannot be overestimated. Veterinary clients should be made aware of health benefits of pet ownership, including reductions in mental illness and cardiovascular disease, decreased blood pressure and improved self-esteem in children.

Owners should be advised not to panic about the possibility of pet infection and transmission, and instead enjoy all the positive healthcare benefits of the bond they have with their pets. On the one hand, restriction of human movement is likely to reduce adoption of pets from shelters, and more animals in need of homes may be euthanized as a result; on the other hand, there has been an increase in animal fostering by those looking for companionship during this shelter-in-place period, and this has raised some concerns that these animals will not receive adequate long-term care or will be abandoned when restrictions are relaxed.

 How should veterinarians advise clients who ask about the potential for their own pets to become infected with COVID-19?

Veterinarians should remain vigilant and watch for signs in animals that might represent COVID-19. However, many animal diagnostic laboratories are not currently set up to test for this specific coronavirus. 

 but are not offering testing at this time. The problem occurs when veterinarians have to perform the testing, because they would need to wear a special high-density face mask and a face shield. Face masks must be fitted in advance by a trained individual, and many veterinarians are not fit-tested on a regular basis, nor do they have high-density surgical masks on hand. Veterinarians should contact their local public health department or the CDC if an infected owner contacts them and requests that their pet be tested.

Should a dog or cat develop respiratory illness, pet owners need to remember that respiratory illnesses (‘kennel cough’ and ‘cat flu’) are extremely common in dogs and cats, especially those that board, attend doggy daycare or are acquired from shelter environments. Owners need to know that more than 10 different viruses and bacteria can cause these signs in dogs and cats, including a canine respiratory coronavirus that only infects dogs.

Any pet that develops respiratory illness is much, much, much more likely to be infected with a canine or feline respiratory virus or bacteria than with the novel coronavirus. These dog and cat viruses do not cause infections in people. Pet owners should be told to have their pet evaluated by a veterinarian if signs of runny nose/eyes, cough or sneezing develop, and they should not allow their pet contact with other animals in the meantime.

 Do you anticipate that cats, dogs or other pets could become vulnerable as the virus mutates?

Coronaviruses are less likely than influenza viruses to mutate significantly. Based on what we’ve seen in the past with both human coronaviruses and influenza viruses transmitted to pets, it is more likely that cats, dogs and other pets will remain as “dead end” hosts rather than becoming more vulnerable to infection and disease.

Articles


A symptomatic cat in Belgium has tested positive for the novel coronavirus, but experts reiterate that there is no proof that animals can transmit the disease.


Cat tests positive for COVID-19, but there is no cause for panic

According to an independent survey of 380 small business customers and 350 small business owners commissioned by business software provider Weave, small businesses that allow clients to pay for services using a variety of methods earn 29% more revenue than those that offer fewer payment options.

“Studies have repeatedly shown that providing more payment options, including Apple Wallet and Google Pay, increases customer satisfaction and encourages repeat business,” Jeff Lyman, Weave’s chief product officer, told dvm360. “Additionally, businesses that do not begin to explore ways to offer expedited services risk falling behind their competitors who can allow clients to take their ill or anxious animal out of a crowded lobby, settle them down and then pay their bill.”

Nearly half of the small businesses surveyed said that the more payment types they accept, the more money they make.

Credit card fees are a major point of contention for business owners and customers alike. Upwards of 35% of small business owners surveyed believe they overpay for credit card transaction fees, and 21% say they’ve had to cut back on spending elsewhere because of processing fees, forgoing investments in marketing, new products and updated technology. But should those fees be passed onto the customer?

Nearly half of the small business owners surveyed (41%) worry that charging a credit card fee will cost them customers—and with good reason. Almost three-quarters of customers surveyed (71%) said they try to avoid businesses that charge fees to use a credit card.

But limiting payment options to check or cash could prompt clients to look for pet care elsewhere. According to the survey findings, more small businesses have lost a sale because they didn’t provide sufficient payment options than because of negative online reviews. In fact, respondents reported, not accepting the right payment options has cost small businesses more customers than inconvenient hours, poor customer service or unfriendly employees.

With online sales in the United States totaling an astronomical 

, many customers are looking for that same purchasing ease at physical locations. While cash, checks and credit cards remain the three most commonly used and accepted forms of payment, they aren’t the only options. Carrying cash is becoming a thing of the past. In fact, only 36% of the customers surveyed say they always carry cash and just 20% are sure they carry enough cash to make a purchase in the stores they frequent.interested in paying via their phone. If given the option, 30% of small business customers would frequently or always pay via text. That number more than doubles to 62% for buyers under 35 (these younger buyers are also nearly twice as likely to avoid small businesses that don’t accept their preferred payment type).

Lyman also suggests that practices consider instituting a text-to-pay option. “This allows the practice to bill for services without forcing clients to wait and pay if an animal is experiencing anxiety in a crowded lobby or if the appointment was a no-show,” he says.

Instead, customers are much more likely to carry a cell phone and a growing number are 

“Billing for no-shows is becoming more of a norm in today's world and without an efficient way to collect those payments, practices are leaving money on the table,” he adds.

Apple Pay and Google Wallet are two of the most popular mobile payment technologies on the market. Each allows users to upload credit card information onto their smartphones. Accepting this form of payment requires two things:

Your hospital must have an account with Apple or Google.

Your point-of-sale terminal must be capable of accepting contactless payment.

To pay via phone, the client simply hovers their phone over the terminal to transfer data and make the payment.

Amanda Carrozza is a freelance writer and editor in New Jersey.

New data highlight another way your veterinary practice may be able to increase revenue: Offer additional payment options. 

Why you should consider adding mobile payment options

To continue caring for patients while maintaining social distance during the COVID-19 crisis, many healthcare providers have turned to telemedicine services, but what about veterinarians?

In its efforts to provide flexibility during this critical time, the U.S. Food and Drug Administration (FDA) says it’s temporarily easing telemedicine requirements for veterinarians so they, too, can use this service to augment patient care during the pandemic, according to an 

“The FDA recognizes the vital role veterinarians play in protecting public health … and during this time, we need to provide veterinarians with the latitude to expand the use of telemedicine in the care of animals, not only pets but also the animals that produce our food,” says FDA Commissioner Stephen M. Hahn, MD, in the release.

“The FDA is providing flexibility that will help veterinarians maintain the health of animals during the pandemic, while allowing for the social distancing that is so important in limiting the further spread of coronavirus disease across the country and the world,” Dr. Hahn adds.

According to current federal and state regulations, before veterinarians can provide telemedicine services they must physically examine an animal and/or make medically appropriate and timely visits to the location where the animal is kept. In other words, the VCPR definition cannot be fulfilled with telemedicine alone.

During this crisis, however, the FDA “generally does not intend to enforce the animal examination and premises visit portion of the VCPR requirements relevant to the FDA regulations governing 

Relaxing these federal regulations will allow veterinarians to prescribe extralabel drugs or authorize the use of VFD drugs without having to first examine the animals, in turn limiting the interactions between veterinarians and other people and decreasing the potential community spread of COVID-19.

For example, a client can send a video of their sick dog to their veterinarian and, if necessary, the veterinarian can prescribe drugs extralabelly, says the FDA. Or, a veterinarian could remotely examine and diagnose a group of food-producing animals with a skin disease, and then authorize the use of certain drugs in the animals’ feed.

What does it mean for small animal practitioners?

This action comes at a time when veterinarians are trying to ramp up the use of telemedicine so they can continue to care for animals while protecting the health of their employees and the public, says dvm360 Chief Veterinary Officer Adam Christman, DVM, MBA. “But the reality is that while relaxing these regulations is beneficial for food animal producers, it doesn't really change much for the small animal general practitioner,” he says.

“An established VCPR—having physically seen the animal within the past 12 months—remains a requirement for practicing telemedicine in most cases,” Dr. Christman continues. In other words, a veterinarian still must physically examine a patient before prescribing any medication that is labeled for dogs or cats.


The agency is temporarily suspending enforcement of certain aspects of the federal veterinarian-client-patient relationship (VCPR) requirements, but state requirements remain in force.


FDA loosens veterinary telemedicine restrictions amid COVID-19 crisis

In horses, administering a caudal epidural anesthetic into the sacrococcygeal or first intercoccygeal space provides regional analgesia to the tail and perineum, thus facilitating surgical procedures of the vagina, cervix, urethra, bladder or rectum, as well as select cases for correction of a prolapsed uterus; it is also helpful for managing dystocia.

A major benefit of performing caudal epidurals in horses is the ability to complete surgery and other invasive procedures with the patient standing; loss of sensory innervation without affecting motor control forgoes the need for and potential risks associated with general anesthesia. In addition, the technique accommodates placement of a catheter in the caudal epidural space for repeated dosing of medications and long-term pain management in horses with specific hindlimb musculoskeletal issues or other conditions.

The horse should be restrained in stocks; judicious use of sedation is paramount. Caution should be taken not to sedate the horse too heavily, which may cause ataxia and impede the animal’s ability to stand squarely, thereby making it more challenging to insert the needle on the midline.

The landmark for needle placement is the first intercoccygeal or sacrococcygeal space, which can be located by raising and lowering the tail. The exact distance from the tail base varies among horses; however, usually the space can be located 2.5 to 5 cm from the origin of the tail hairs.

 This area should be clipped and aseptically prepared. Optionally, a small bleb of local anesthetic, either lidocaine or 2% mepivacaine, may be placed under the skin at the proposed site of injection.

An 18-ga, 1.5-inch needle should be inserted with the bevel facing cranially on the midline and perpendicular to the surface of the skin for a more accurate trajectory to the space; it should not be inserted perpendicular to the floor (

). Once the needle is through the skin, the hub can be filled with sterile saline or the anesthetic solution (

As the needle is advanced in the correct location (

), it will puncture the arcuate ligament, thus creating a popping sensation for the practitioner; fluid within the hub will then be aspirated into the epidural space via negative pressure. This procedure, known as the hanging drop technique, confirms accurate needle placement and accommodates using minimal pressure for injection of the local anesthetic. If the needle hits bone, it should be withdrawn approximately 0.5 cm, but not removed from the skin, and redirected. Loss of anal sphincter tone is a common finding when caudal epidural anesthesia is achieved.

 With the hanging drop technique, the hub of the needle is filled with anesthetic solution and the desired needle position is confirmed.

 The needle is slowly advanced until the anesthetic solution is aspirated into the caudal epidural space, confirming accurate placement. Then the remaining anesthetic solution is injected.

Commonly used anesthetics are xylazine and lidocaine or 2% mepivacaine. Xylazine has the benefit of analgesia without ataxia, while detomidine has a profound analgesic effect but can cause undesirable ataxia. Using a combination of 2% mepivacaine (1-2 ml) and xylazine (50-100 mg) diluted to a total volume of 7 to 10 ml using sterile water or sterile saline has been successful in many surgical cases. Combining the two drugs can also produce longer analgesia with only mild ataxia, as compared with using either agent alone.

 Morphine can also be combined with an alpha-2 agonist for prolonged analgesia in select hindlimb musculoskeletal disorders.

Horses should be checked to ensure that sensory innervation has returned to the hindlimbs before they are moved out of the stocks. Turning horses out in a small paddock for a few hours after the procedure may be prudent, rather than possibly risking being cast if they are returned to their stall.

Contraindications to use of the caudal epidural technique include neurologic or musculoskeletal disease, or local inflammation surrounding the injection site. A caudal epidural presents low risk for puncture of the dura and subsequent leakage of cerebrospinal fluid, while keeping motor function intact with the use of appropriate analgesic doses.

In some cases, motor blockage may occur from cranial diffusion of alpha-2 agonists or anesthetic agents; however, this is associated with the use of doses above recommended values and with high volumes of solution. Studies have shown that cranial diffusion of the solution up to six to 10 vertebral spaces can occur when doses between 10 and 20 ml are used, with the consequential risk for motor nerve paralysis.

 Therefore, the total volume of solution should be less than 10 ml. In horses that have had previous caudal epidurals, a lower total volume (< 10 ml) should be used, as previous injections can make the space smaller, allowing for more cranial migration of the anesthetic solution.

Of note, although rare, some combinations of local anesthetics and alpha-2 agonists have reportedly caused severe ataxia or recumbency, even when used at recommended doses.

 Side effects can be reduced by good patient selection and the use of appropriate doses. Inadequate analgesia can result from incorrect injection technique or abnormal anatomy (e.g. presence of fibrous lesions from previous epidurals), which may result in unilateral effects. Infection can be minimized by thorough sterile preparation of the injection site and aseptic technique.

1. Robinson EP, Natalini CC. Epidural anesthesia and analgesia in horses. 

2. Grubb TL, Riebold TW, Huber MJ. Comparison of lidocaine, xylazine, and xylazine/lidocaine for caudal epidural analgesia in horses. 

3. Hendrickson DA, Southwood LL, Johnson R, Kruse-Elliot K. Cranial migration of diﬀerent volumes of new-methylene blue after caudal epidural injection in the horse. 

4. Skarda RT, Muir WW. Analgesia, hemodynamic and respiratory effects of caudal epidurally administered ropivacaine hydrochloride in mares

Dr. Barton graduated from the Royal Veterinary College in London and is currently completing a surgery internship at Hagyard Equine Medical Institute in Lexington, Kentucky. In addition to equine surgery, she has an interest in neurology and lameness diagnosis. Dr. Sandow is a board-certified veterinary surgeon at Hagyard Equine Medical Institute. His interests include orthopedics, lameness and emergency celiotomy as well as dystocia.

Surgery STAT is a collaborative column between the American College of Veterinary Surgeons (ACVS) and 

 magazine. To locate a diplomate, visit ACVS's 

, which includes practice setting, species emphasis and research interests, at 

Caudal epidural anesthesia allows for invasive procedures while the horse is sedated in standing position without pain or discomfort. 

Surgery STAT: How to perform a caudal epidural in horses

Pets and people share environments, which means they also share parasites and their associated zoonotic diseases. Perhaps the scariest of the blood-sucking hangers-on are ticks. But our understanding of tick parasitism has been sparse thus far.

An 2007 review of more than two million veterinary records in 40 states found ticks that ticks were present on 1.3% of dogs.

 Yet until now, little was known about the respective prevalence of individual tick species and their specific life stages on dogs and cats. In a large-scale study conducted by investigators at Oklahoma State University, ticks collected from pets were identified by species, gender and life stage; characterized by attachment site; and delineated by month and geographic location found.

From February 2018 to January 2019, tick submissions were solicited from 190 veterinary practices throughout the United States: A total of 10,978 ticks were harvested from 1,494 dogs and 336 cats.

Veterinary practices were provided with kits that facilitated submission and sample quality control. Sample data included tick removal date; geographic location and attachment site on pet; age, gender, weight and spay/neuter status of pet; and estimated percentage of time the pet spends outdoors.

Morphologic examination was conducted on each tick to determine its genus/species, gender and life stage. Molecular identification was used when morphologic identification was precluded by specimen damage or ambiguity.

Ticks were submitted every month of the year, with the highest numbers of ticks recovered from both dogs and cats in July, from the South and Midwest.

Canine tick submissions originated at 263 veterinary hospitals in 49 states, and data were collected for most of the dogs. They ranged in age from 40 days to 19 years, with an average weight of 20 kg. Gender and neuter status did not differ significantly from the general population, although fewer dogs were spayed than in the general population (63.1% vs. 67.4%).

 Half of the dogs spent more than 30% of their time outdoors.

Although one dog was infested with over 4,700 ticks, only 5.5% of the 1,494 dogs in the study bore more than nine; most had just a single tick.

A total of 14 tick species were identified among the canine samples. The greatest portion of dogs—35.6%—was infested with the American dog tick, 

was found on27.4% of dogs, followed by the Lone Star tick, 

(11.4%). A smaller number of dogs were infested with 

 Co-infestations with more than one tick species were documented for 93 dogs (6.2%).

When investigators tabulated tick species with respect to percentage of total ticks, the brown dog tick was by far the most prevalent in the canine samples, at 62%; the presence of this large number of ticks—6,252—on a mere 174 dogs suggests large groupings of larvae/nymphs, which can number a few thousand in a single hatch. The Lone Star tick composed 19.1% of submissions; the American dog tick, 10.2%; and the black-legged tick, 5.7%.

Attachment site data from single-species infestations of adult ticks (available for over half of the canine submissions) showed species distinctions in attachment site preference. The American dog tick, the black-legged tick and the brown dog tick were more commonly attached dorsally, specifically to the head, ears and neck; brown dog ticks were also attached, albeit less frequently, on the abdomen, axillae, groin, legs and paws. The Lone Star tick was more commonly attached ventrally, to the abdomen and axillary/inguinal regions.

Feline submissions came from 109 veterinary clinics in 39 states. Cats ranged in age from 18 days to 18 years, and averaged 4.4 kg. Fifty-nine percent were male compared with 49.6% for the general pet cat population; a disproportionately small percentage of the cats were sterilized.

 Over 56% of the cats were reported to spend more than 70% of their time outdoors.

Infestation intensities ranged from one to 38 ticks, with an average of 2.6 ticks collected from each cat. Twelve tick species were identified. The black-legged tick was present on 46.4% of the cats, the Lone Star tick on 29.5% and the American dog tick on 17.9%. A smaller number of cats hosted 

O. megnini, R. sanguineus, A. maculatum, H. longicornis,

 species. Co-infestations were documented in 14 cats (4%).

Most tick submissions consisted of the Lone Star tick (38.5%), the black-legged tick (32.2%) and the American dog tick (13.7%).

Attachment site data from single-species infestations were provided for 33 cats (10%). As in the dog sample, the American dog tick and the black-legged tick were more commonly attached dorsally, and the Lone Star tick ventrally (tail and perianal region in cats).

Several new findings were generated by this study. First, the primary ticks parasitizing the dogs were the brown dog tick, the Lone Star tick and the American dog tick, composing 95% of submissions. For the cats, the Lone Star tick, the American dog tick and the black-legged tick accounted for 80% of samples.

Although some 40% of the ticks removed from dogs and cats in this study were adults—primarily females—nearly half were larvae and 16% were nymphs. Larvae and nymphs constituted the majority of submissions of Lone Star ticks from dogs and cats; in dogs, larvae and nymphs constituted the majority of brown dog tick submissions. This finding confirms that immature stages of some common tick species are significant players in tick parasitism of pets. It also suggests the importance of tick control, as these small stages can be overlooked easily.

The study also revealed an expanding geographic distribution of certain tick species, such as the Gulf Coast tick (

),and a year-round presence of feeding ticks in this country.

While most pets in this study had outdoor access, a small portion were reported to rarely or never go outside, suggesting that ticks hitch rides indoors on clothing and other pets.

Investigators also concluded that cats may be underrepresented as hosts for ticks: While they outnumber dogs as pets in the U.S.,

 cats accounted for only 20% of tick submissions in this study. However, the data in this study were generated by veterinary visits, which are fewer overall for cats than dogs.

Dr. Joan Capuzzi is a small animal veterinarian and journalist based in the Philadelphia area.

A flagship study details tick infestations in pet dogs and cats in the United States.