Progress towards Companion Animal Zoonotic Disease Surveillance in the U.S. Army

ObjectiveWe assesed the feasibility of a zoonotic disease surveillance system through the current EHR (ROVR) for all POAs and GOAs. Additionally, we conducted a retrospective observational study querying and collecting reported zoonoses of interest, for 2017.IntroductionDogs, cats and other companion animals have played an integral role in many aspects of human life. Human and companion animal (CAs) interactions have a wide range of benefits to human health1–3. The threat of zoonotic transmission between CAs and humans is exacerbated by proximity (56% of dog owners and 62% of cat owners sleep with their animal next to them4) and the number of diseases CAs share with humans. Many of these highlighted zoonoses are spread by direct contact, and others are vector-transmitted (e.g., fleas, ticks, flies, and mosquitos). Within the realm of the One-Health concept, CAs can serve multiple roles in zoonotic transmission chains between humans and animals. They can serve as intermediate hosts between wildlife reservoirs and humans, or as possible sentinel or proxy species for emerging diseases5. Given the large number of CAs within the United States (estimated 72 million pet dogs, 81 million pet cats), understanding and preventing the diseases prevalent in CA populations is of utmost importance.Biosurveillance is a critical component of One Health initiatives including zoonotic disease mitigation and control. As Lead Service for Veterinary Animal and Public Health Services, the Army has a responsibility to champion biosurveillance efforts to support One Health initiatives, improving Servicemember, family, and retiree health across the Joint Force. Additionally, with military personnel experiencing apparent increased rates of job-reducing ailments such as diarrheal, bacterial and viral disease6–8, it is essential that the Army focus on maximizing their operational potential by minimizing the amount of time personnel are sick from these transmissible diseases and observing potential sources of infection. By observing the zoonotic disease burden in privately owned (POAs) and government-owned (GOAs) animals, public health investigators can increase focus on what transmittable diseases are at greatest risk of being spread from companion animals to military personnel.To address this potential source of infection, the Department of Defense (DoD) sought and continues to seek to establish a centralized and integrated veterinary zoonotic surveillance system to provide Commanders with a clear picture of disease burden9. With this assigned responsibility, the Army Veterinary Service (VS) seeks to centralize and enhance surveillance efforts through the Remote Online Veterinary Record (ROVR) Electronic Health Record (EHR), an enterprise web-based application to support the Army VS, accurately establishing a zoonotic epidemiological baseline and sustaining consistent future reporting.MethodsThrough a requested effort and proof of concept, the Army Public Health Center’s (APHC) One Health Division tested the feasibility of a zoonotic disease surveillance system through the current EHR (ROVR) for all POAs and GOAs. We obtained one year (2017) worth of zoonotic encounters of interest through ROVR, querying a population of roughly 202,000 animals (n=202,217). We conducted a retrospective observational study comparing reported zoonoses of interest between CA populations. Maximum Likelihood Estimations of frequency detailed comparisons of frequency and prevalence between GOAs and POAs, within the ROVR EHR. Additionally, we evaluated the accuracy of surveillance data queried, proposed potential metrics and dashboards for commanders and stakeholders to easily observe zoonotic burden of companion animals and developed potential courses of action for future tools, collaborations, and educational interventions.ResultsOf the 512 collected zoonotic encounters, Giardia and Hookworm were the two most prevalent zoonoses overall, with 4.23 and 5.43 cases per 10,000 outpatient visits (OPVs), respectively. We observed a significant differential frequency of Giardia and Hookworm between GOAs and POAs (63% (CI: 54.6-71.4) vs 12.7% (CI: 9.7-16.1) and 2.5% (CI: 0.1-5.9) vs 41.9% (CI: 37.1-46.8) of all queried zoonotic diseases of interest, respectively). In addition to back-end database and querying improvements, we suggested the development of an educational intervention based at Army First-Year Graduate Veterinary Education program (FYGVE) locations to emphasize the important benefits of capturing zoonotic diseases of interest correctly, early stages in the clinical experience. The intervention would focus on increasing accurate data capture with the ultimate goal of a phased regional rollout through education and collaboartive buy-in.ConclusionsFrom these results and recent CDC guidance of data-driven surveillance, we’ve proposed a phased surveillance development plan focused on systematic data collection, collaboration, and evaluation. Our idenfitied overexpressed zoonoses will focus our efforts on tracking Giardia and Hookworm through multi-year trends. This assessment and proof of concept allows for illumination of gaps and limitations within the Army VS to effectively track the zoonotic burden of GOA and POA populations. Our current and future work will look to close surveillance gaps and help identify potential routes of transmission from companion animals to humans.References1. Edney AT. Companion animals and human health: an overview. J R Soc Med. 1995 Dec;88(12):704p-708p.2. Wells DL. The Effects of Animals on Human Health and Well-Being. Journal of Social Issues. 2009 Sep 1;65(3):523–43.3. O’Haire M. Companion animals and human health: Benefits, challenges, and the road ahead. Journal of Veterinary Behavior: Clinical Applications and Research. 2010 Sep 1;5(5):226–34.4. Krahn LE, Tovar MD, Miller B. Are Pets in the Bedroom a Problem? Mayo Clinic Proceedings. 2015 Dec 1;90(12):1663–5.5. Day MJ, Breitschwerdt E, Cleaveland S, Karkare U, Khanna C, Kirpensteijn J, et al. Surveillance of Zoonotic Infectious Disease Transmitted by Small Companion Animals. Emerg Infect Dis. 2012 Dec;18(12):e1.6. Cook GC. Influence of diarrhoeal disease on military and naval campaigns. J R Soc Med. 2001 Feb 1;94(2):95–7.7. Sanchez JL, Gelnett J, Petruccelli BP, Defraites RF, Taylor DN. Diarrheal disease incidence and morbidity among United States military personnel during short-term missions overseas. The American journal of tropical medicine and hygiene. 1998;58(3):299–304.8. Russell KL, Hawksworth AW, Ryan MAK, Strickler J, Irvine M, Hansen CJ, et al. Vaccine-preventable adenoviral respiratory illness in US military recruits, 1999–2004. Vaccine. 2006 Apr 5;24(15):2835–42.9. Richardson TR. DoD Directive 6400.04E: DoD Veterinary Public and Animal Health Services [Internet]. Monterey, California. Naval Postgraduate School; 2000 [cited 2017 Jul 26]. Available from: http://calhoun.nps.edu/handle/10945/9216

Adaptation of the One Health Zoonotic Disease Prioritization Tool for Government and Privately Owned Companion Animal Zoonotic Disease Surveillance

The U.S. Army Veterinary Services (AVS) provides public health guidance, consultation, and clinical support regarding zoonoses for the Department of Defense (DoD). AVS One Health Division was tasked with developing a surveillance tool for zoonoses of companion animals presenting to DoD veterinary facilities. Such a tool could help monitor the spread of zoonoses between U.S. military Service Members, their family members, and their pets. The primary objective was to prioritize zoonoses of interest for companion animal disease surveillance in the DoD. AVS implemented a semi-quantitative One Health approach to prioritize zoonoses of interest. The prioritization process followed five steps: (1) generate list of zoonoses to be ranked that are applicable to a DoD companion animal disease surveillance system, (2) develop criteria to identify the importance of a zoonoses, (3) develop criteria definition questions, (4) rank criteria, and (5) rank zoonoses. The prioritization process resulted in a ranked list of 14 zoonoses of interest which was presented to AVS leadership with three potential courses of action. Twelve zoonoses were selected for inclusion in DoD Companion Animal Disease Surveillance. The prioritized list of diseases was the first step in developing a DoD companion animal disease surveillance effort. Mirroring such an approach in civilian companion animal populations could fill a critical public health gap

Opportunistic infections and AIDS malignancies early after initiating combination antiretroviral therapy in high-income countries

Background: There is little information on the incidence of AIDS-defining events which have been reported in the literature to be associated with immune reconstitution inflammatory syndrome (IRIS) after combined antiretroviral therapy (cART) initiation. These events include tuberculosis, mycobacterium avium complex (MAC), cytomegalovirus (CMV) retinitis, progressive multifocal leukoencephalopathy (PML), herpes simplex virus (HSV), Kaposi sarcoma, non-Hodgkin lymphoma (NHL), cryptococcosis and candidiasis. Methods: We identified individuals in the HIV-CAUSAL Collaboration, which includes data from six European countries and the US, who were HIV-positive between 1996 and 2013, antiretroviral therapy naive, aged at least 18 years, hadCD4+ cell count and HIV-RNA measurements and had been AIDS-free for at least 1 month between those measurements and the start of follow-up. For each AIDS-defining event, we estimated the hazard ratio for no cART versus less than 3 and at least 3 months since cART initiation, adjusting for time-varying CD4+ cell count and HIV-RNA via inverse probability weighting. Results: Out of 96 562 eligible individuals (78% men) with median (interquantile range) follow-up of 31 [13,65] months, 55 144 initiated cART. The number of cases varied between 898 for tuberculosis and 113 for PML. Compared with non-cART initiation, the hazard ratio (95% confidence intervals) up to 3 months after cART initiation were 1.21 (0.90-1.63) for tuberculosis, 2.61 (1.05-6.49) for MAC, 1.17 (0.34-4.08) for CMV retinitis, 1.18 (0.62-2.26) for PML, 1.21 (0.83-1.75) for HSV, 1.18 (0.87-1.58) for Kaposi sarcoma, 1.56 (0.82-2.95) for NHL, 1.11 (0.56-2.18) for cryptococcosis and 0.77 (0.40-1.49) for candidiasis. Conclusion: With the potential exception of mycobacterial infections, unmasking IRIS does not appear to be a common complication of cART initiation in high-income countries