Chapter 1 - Zoonotic Ascarids and Hookworms: Your Role in Preventing Human Disease

Your veterinary team plays a critical role in preventing the transmission of zoonotic diseases from pets to
people. Here's what you need to know about the latest research and proven treatment guidelines.
By Peter M. Schantz VMD, PhD

Test Your Current Knowledge

Do you understand the most common zoonotic infections associated with pets? Before studying
this chapter, take this pre-test to check your awareness of ascarids and hookworms. Answers
can be found in the Chapter Review.
1. Ascarids (roundworms) and hookworms of dogs and cats have long been recognized as
potentially causing human disease. True or False?
2. Stool examinations are a reliable method to detect worms in young puppies. True or False?
3. Deworming puppies, kittens, and their mothers is the most effective method to avert disease in
pets and prevent environmental contamination. True or False?
4. The larvae of Ancylostoma braziliense and Ancylostoma caninum, common hookworms of
dogs and cats, cannot penetrate the skin of humans. True or False?
5. Puppies have a high prevalence of Toxocara infection because they acquire infections from
their mothers, which transfer larvae prenatally or via milk. True or False?

As a veterinary professional, you're on the front lines helping to prevent the transmission of zoonotic disease
agents from pets to people. Clients see you as a trusted source of information for their pets, and they seek
advice about potential zoonotic disease risks of pet ownership and how to avoid them. Physicians also are
concerned about pets as potential sources of infections; however, they are unlikely to know their patients'
pet ownership status until after disease transmission has already occurred- then it's too late for prevention!
Because you occupy an influential position in helping prevent zoonotic disease, you should continually
upgrade your knowledge of these diseases, including the risks for infection and how to help prevent them.

To illustrate your role in preventing human disease, let's review the current status of two well-known
parasitic agents of zoonotic disease: ascarids (Toxocara spp.), also known as roundworms, and hookworms
(Ancylostoma spp.). Ascarids and hookworms of dogs and cats have long been recognized as potentially
causing human disease.

Figure 1 - Adult and immature ascarids (roundworms) have been recognized as potential causes of human
disease.

Chapter 1 - Understanding Ascarids (Roundworms)

Ascarids (Roundworms)
- Toxocara canis
- Toxocara cati
- Toxascaris leonina
 Figure 2 - At least 750 cases of ocular larva migrans occur in the United States each year.

Toxocaral larva migrans, or infection by the common ascarid worms of dogs and cats, is a common zoonotic
infection associated with pets in the United States and other industrialized countries.1 The Centers for
Disease Control and Prevention (CDC) estimates this infection causes hundreds of unilateral blindness
cases and uncountable numbers of less permanent forms of illness in children annually in the United States
(Figure 2).2,3 About 45 years ago, when Toxocara worms were first discovered to cause human disease,
most of the knowledge of how to prevent it became apparent.4 Its continuing importance as a cause of
zoonotic infection is somewhat disconcerting, especially given the availability of safe and effective drugs to
eliminate these infections in pets.

Figure 3 - Puppies may acquire infections from their mothers; larvae may be transmitted prenatally or via
milk.

As a veterinary professional, you're ideally positioned to limit transmission of toxocariasis. Some surveys
suggest that the prevalence of intestinal helminth infections in dogs has declined during the last 20 years5,6;
however, this conclusion is misleading. Those studies are from university veterinary clinics, where most
canine patients are referrals and were likely to have been previously treated with anthelminthic drugs.
Intestinal helminths remain prevalent in dogs and cats that have not been treated, as seen in the study we
performed on shelter dogs in Atlanta, Georgia. This study confirmed that ascarids, hookworms, whipworms,
and flea-transmitted tapeworms remain prevalent in these dogs, the majority of which had spent time in or
 around human households. In dogs 7 weeks to 3 months old, prevalence of Toxocara infection was nearly
100%. Although 80% of dogs 6 weeks old or younger had worms in their intestine, only 20% were positive
for Toxocara eggs on stool examination, illustrating why young puppies must be treated. Stool examinations
are not reliable in young puppies because worms are often not fully mature. Common reasons for false-
negative stool examination results include poor technique or insufficient fecal material.7

A recent national survey found that intestinal helminths are prevalent in dogs and cats that have not been
previously treated with anthelminthic drugs. The study examined 6,458 fecal specimens from animal shelters
nationwide and discovered that 52% of dogs sampled in the Southeast and 36% of dogs sampled nationally
harbored either Toxocara canis, Ancylostoma spp., or Trichuris vulpis.8

Puppies have a high prevalence of Toxocara infection because they acquire infections from their mothers,
which transfer larvae prenatally or via milk (Figure 3).9 Unless anthelminthic treatments are administered
before 4 weeks of age, puppies will contaminate the environment because female worms become fully
mature and produce eggs when puppies are 3 weeks of age.10 These eggs remain infective in most
environments for months or even years.

Surveys by the American Veterinary Medical Association estimate that more than half of American
households own dogs or cats, or both.11 This fact, combined with high rates of Toxocara infection in these
pets, could produce widespread environmental contamination with Toxocara eggs, thus serving as a
potential source of infection for humans, particularly children whose play habits put them most at risk.2,3

The disease produced by Toxocara infection depends on how many larvae are ingested, the frequency of
reinfection, and other factors still poorly understood.12 The majority of human infections with Toxocara
larvae are well tolerated, even asymptomatic; however, a proportion of infected persons develop larva
migrans syndromes that may be either systemic or confined to the eye. When a larva invades the eye,
known as an ocular larva migrans, it may leave the person partially or totally blind in that eye. According to
CDC data, a minimum of 750 cases of ocular larva migrans occur every year in the United States. When a
person ingests soil contaminated with an infected dog's feces, that person may experience symptoms of
nausea, fever, edema, and even seizures. Annual cases of this illness, known as visceral larva migrans
syndrome, are much greater than ocular larva migrans; however, the CDC's estimates are imprecise.3

Several serologic surveys of children and adults show that exposure to Toxocara was more common than
the CDC was aware.2 The principal risk factors for infection include the presence of a household dog,
particularly a puppy, in the person's household within 6 months of onset of illness.13 When combined with
pica behavior, like eating dirt, the statistical association becomes strong. Many pet owners don't know that
pets might carry illnesses that may be transmitted to people.13 While pet owners are well informed about
rabies and the need to vaccinate pets, their knowledge of other zoonotic risks is minimal or misinformed.14
With proper education, pet owners can take simple precautions that protect their families and pets (see
Chapter 2, for a list of precautions).

Chapter 1 - Understanding Hookworms

Hookworms
- Ancylostoma braziliense
- Ancylostoma caninum
 Figure 4 - Child with Cutaneous Larva Migrans (CLM) - prolonged migration of hookworm larvae in skin
causes lesions known as "creeping eruption".

The larvae of Ancylostoma braziliense and Ancylostoma caninum, common hookworms of dogs and cats,
may penetrate the skin of human hosts as well as the preferred canine and feline host. When people have
contact with soil or sand contaminated by the feces of dogs and cats infected with hookworms, they can
develop progressive linear eruptive lesions, a syndrome called cutaneous larva migrans or "creeping
eruption" (Figure 4) Prolonged migration of larvae in the skin causes progressive linear eruptive lesions.

Most infections are seen in people who have crawled beneath a raised building to work on plumbing or
electrical wiring, or in sunbathers unfortunate enough to recline on wet sand contaminated by hookworm
larvae. Ordinarily, lesions are self-limiting, and the intense itching subsides progressively and completely
within a few weeks. In cases of mass infection, larvae may penetrate into deeper tissues, such as the case
of a man who developed pulmonary symptoms and larval invasion of the skeletal muscles in association
with severe cutaneous larva migrans. Visceral larva migrans syndrome, ordinarily associated with Toxocara
infection, also has been recognized with Ancylostoma caninum, causing pneumonitis, chest pains, cough,
and pulmonary radiographic changes. Partial blindness, called corneal opacities, associated with
"Ancylostoma type" larvae also has been observed.

Figure 5 - Ancylostoma caninum has been linked

to human disease in both the U.S. and Australia.

Recent reports from the United States and Australia also relate Ancylostoma caninum to human intestinal
manifestations. Patients developed isolated digestive symptoms such as abdominal pain of variable
intensity, diarrhea, abdominal distention, weight loss, and rectal bleeding. Colonoscopy or laparotomy
findings included a feeding or an attached hookworm in every case and either intestinal obstruction, mucosal
ulceration, or peritonitis. In six patients, the worm was identified as Ancylostoma caninum (Figure 5). All
worms were immature, and the females were not producing eggs. Worms were located in the lower
gastrointestinal tract (terminal ileum, cecum, transverse colon, and rectum). Patients recovered completely
after removal of the hookworm.

Presumed canine hookworm infections from two young children with eosinophilic enterocolitis have been
reported recently in the southern United States. The children were treated successfully with mebendazole.
Such infections probably occur commonly in the United States but are unlikely to be diagnosed correctly
because of lack of awareness.

Chapter 1 - Your Role in Prevention

To assess methods that would lead to preventing diseases caused by zoonotic roundworms (toxocariasis
and ancylostomiasis), the CDC surveyed practicing veterinarians in 1979 and 1989. Unfortunately,
 veterinarians' recommendations to pet owners are less than ideal to prevent transmission.15,16 Less than
half of surveyed veterinarians took the preventive, or prophylactic, approach to treating roundworms. When
asked at what age they recommend first examination or treatment for intestinal worms, only a third of
veterinarians said at 4 weeks of age or less, which is the timing necessary to efficiently prevent excretion of
Toxocara eggs. Another third of surveyed veterinarians recommended examinations or treatments beginning
at 7 or more weeks of age, increasing the likelihood that environmental contamination occurred for at least a
month before the puppy was examined. These surveys show that many veterinarians are ambivalent about
discussing the potential zoonotic hazards of roundworms and hookworms with clients.

Deworming puppies, kittens, and their mothers is the most effective method to avert disease in pets and
prevent environmental contamination because they have the highest worm burdens, are most vulnerable to
the ill effects of these infections, and are the main sources of infective stages. Preventive treatments in
puppies and kittens must be initiated shortly after birth. You should give anthelmintic drugs repeatedly to
puppies at 2, 4, 6, and 8 weeks of age. Because prenatal infection does not occur in kittens, egg excretion
begins later than in puppies, and cats' acquisition of roundworms and hookworms are comparatively less in
most U.S. areas, you should start preventive treatments at 6 weeks of age and repeat at 8 and 10 weeks in
kittens. Nursing mothers need treatment concurrently because they often develop infections at the same
time as their offspring. The earliest treatments require providing clients with medications to administer to
their pets at home. You can help prevent roundworm and hookworm infection in older dogs and cats with
periodic treatments of drugs whose efficacy is limited to intestinal nematodes, or prescribe treatment based
on the results of periodic stool examinations. In areas where heartworm infection is enzootic, you can
prescribe heartworm preventives that also work effectively for roundworm and hookworm treatment and
control.

Deworm puppies:
- Starting at 2 weeks of age
- Repeat at 4, 6, and 8 weeks of age
Deworm kittens:
- Starting at 6 weeks of age
- Repeat at 8 and 10 weeks of age

Veterinary professionals can choose from several anthelmintic drugs that are safe and effective against
roundworms, hookworms, and other intestinal helminths of dogs and cats. Anthelmintic drugs are available
in tablet, granule, liquid, and other formulations, whose manufacturers recommend single or multiple daily
doses, and periodic or continuous administration. Select a drug based on the efficacy for the range of
helminth species prevalent in your area. For treatment of very young puppies, use an anthelmintic drug
approved for nursing puppies (2-3 weeks of age). The drug should have a range of efficacy that includes
both roundworms and hookworms (unless one or the other of these species is not present in your area).

Based on the frequency of roundworm and hookworm infection in puppies and kittens and the difficulties of
diagnosing these infections early, you should take a preventive approach to treatment. Severe disease and
even death may occur before roundworms and hookworms become fully mature and begin producing eggs
and, therefore, cannot be diagnosed by stool examinations. Because many puppies and kittens are not
brought to see a veterinarian before 6 to 8 weeks of age, delaying treatment means infections will manifest
and result in environmental contamination with eggs or larvae. Finally, because young animals acquire new
infections continuously from their mothers' milk and the environment, and many worms are not yet fully
mature, fecal examinations are often falsely negative in puppies and kittens.

To help veterinarians and their healthcare teams, the American Association of Veterinary Parasitologists
(AAVP) and the CDC prepared recommendations on treating roundworms and hookworms in dogs and cats.
Strategically-timed preventive anthelmintic treatments for dogs and cats are outlined in the AAVP/CDC
guidelines, "How to Prevent Transmission of Intestinal Roundworms from Pets to People." To get the latest
information, visit the CDC's website at www.cdc.gov/ncidod/dpd/parasites/ascaris/prevention.pdf. You'll find
guidelines on deworming young and adult pets, preventive treatments, information for immunocompromised
pet owners, and much more. The CDC also offers "Preventing Infections from Pets: A Guide for People with
HIV Infection" online at www.cdc.gov/hiv/pubs/brochure/oi_pets.htm, or call (800) 458-5231 to order
brochures. The CDC has distributed more than 70,000 copies of its guidelines to veterinary hospitals
nationwide. Given our knowledge of zoonotic diseases and the availability of safe and effective anthelmintic
drugs, there is no excuse for not preventing the spread of infection. As a veterinary professional, you can
teach clients about zoonotic diseases and explain how to help protect their pets with preventive medication,
 fecal exams, and strategic deworming.

The preventive approach to controlling intestinal parasites also can generate practice income. Surveys
confirm that more than 80% of dog owners and 62% of cat owners visit their veterinarians at least once per
year, and pet owners look to you as the major source of pet-health information.17 Discussing parasite
control and zoonotic diseases helps you strengthen your relationships with clients.18 You can show concern
for the family and demonstrate that you have the knowledge and services to protect the health of pets as
well as family members.

Chapter 1 - Review: Zoonotic Ascarids and Hookworms, Your Role in Preventing Human Disease

• Clients see you as a trusted source of information for their pets, and they seek advice about

potential zoonotic disease risks of pet ownership and how to avoid them. Physicians also are concerned

about pets as potential sources of infections; however, they are unlikely to know their patients' pet

ownership status until after disease transmission has already occurred-then it's too late for prevention!
• Toxocaral larva migrans, or infection by the common ascarid worms of dogs and cats, is a common

zoonotic infection associated with pets in the United States and other industrialized countries.
• As a veterinary professional, you're ideally positioned to limit transmission of toxocariasis. Some

surveys suggest that the prevalence of intestinal helminth infections in dogs has declined during the last

20 years; however, this conclusion is misleading.

• A national survey of shelter dogs showed that almost 36% of all dogs sampled and 52% of those

sampled from the Southeastern states harbored either Toxocara canis, Ancylostoma spp., or Trichuris

vulpis.
• Stool examinations are not reliable in young puppies because worms are often not fully mature.

Common reasons for false negative stool examination results include poor technique or insufficient fecal

material.
• Puppies have a high prevalence of Toxocara infection because they acquire infections from their

mothers, which transfer larvae prenatally or via milk. Unless anthelminthic treatments are administered
before 4 weeks of age, puppies will contaminate the environment because female worms become gravid

and produce eggs when puppies are 3 weeks of age.

• The majority of human infections with Toxocara larvae are well tolerated, even asymptomatic;

however, a proportion of infected persons develop larva migrans syndromes that may be either systemic

or confined to the eye. When a larva invades the eye, it almost always leaves the patient partially or

totally blind in that eye. According to CDC data, a minimum of 750 cases of ocular larva migrans occur

every year in the United States.

• The larvae of Ancylostoma braziliense and A. caninum, common hookworms of dogs and cats, will

penetrate the skin of human hosts as well as the preferred canine or feline host. In humans, they can

cause a syndrome called cutaneous larva migrans or "creeping eruption."

• When asked at what age they recommend first examination or treatment for intestinal worms, only
 a third of veterinarians said at 4 weeks of age or less, which is the timing necessary to efficiently prevent

excretion of Toxocara eggs.

• Preventive treatments in puppies and kittens must be initiated shortly after birth. You should give

anthelmintic drugs repeatedly to puppies at 2, 4, 6, and 8 weeks of age. Because prenatal infection does

not occur in kittens, egg excretion begins later than in puppies, and cats' acquisition of roundworms and

hookworms are comparatively less in most U.S. areas, you should start preventive treatments at 6 weeks

of age and repeat at 8 and 10 weeks. Nursing mothers should be treated concurrently.

• In areas where heartworm infection is enzootic, you can prescribe heartworm preventives that also

work effectively for roundworm and hookworm protection.

Chapter 1 Pre-Test Answers:

1. Ascarids (roundworms) and hookworms of dogs and cats have long been recognized as potentially
causing human disease. True
2. Stool examinations are a reliable method to detect worms in young puppies. False
3. Deworming puppies, kittens, and their mothers is the most effective method to avert disease in pets and
prevent environmental contamination. True
4. The larvae of Ancylostoma braziliense and Ancylostoma caninum, common hookworms of dogs and cats,
cannot penetrate the skin of humans. False
5. Puppies have a high prevalence of Toxocara infection because they acquire infections from their mothers,
which transfer larvae prenatally or via milk. True

Chapter 2 - Zoonotic Diseases: The Human Health Perspective

Although more than 100 zoonotic infections exist, you need to educate clients about the most common
culprits: bite-related, gastrointestinal, and skin-related diseases. It's also important to discuss precautions for
immunosuppressed people.
By Andrew J. Schuman M.D.

Test Your Current Knowledge

Is your veterinary team properly educating clients about zoonotic diseases that can be
transmitted from pets to people? Before studying this chapter, take this pre-test to check your
awareness of common zoonotic diseases. Answers can be found in the Chapter Review.
1. When discussing zoonotic diseases with clients, you should ask pet owners if the immune
status of any household member has changed since their pets were last seen. True or False?
2. Researchers estimate that more than 45% of human ringworm is contracted from infected cats
and dogs. True or False?
3. Growing evidence suggests that Giardia can be transmitted from pets to pet owners and vice
versa. True or False?
4. When a household dog or cat bites a pet owner, physicians often prescribe prophylactic
antibiotics because approximately 30% of cat bites and 50% of dog bites become infected. True
or False?
5. Zoonotic diseases are more commonly encountered in children because they may provoke
biting or scratching, go barefoot during warm weather, and may not wash their hands following
handling household pets. True or False?

Physicians who care for the varied health needs of adults and children often forget that more than half of
U.S. families include household pets as extended family members. Just as human illnesses are transmitted
from one family member to another, pets may expose their owners to a variety of zoonotic diseases. When
talking with their respective clients, physicians and veterinarians must communicate the potential for
transmission of infectious agents from pets to pet owners, and more rarely from owners to pets. Because
more than 40% of immunosuppressed individuals, such as those with Acquired Immunodeficiency
Syndrome (AIDS) or undergoing cancer treatment, own a companion animal, the prevention of zoonotic
 disease is just as important as its timely diagnosis.1 This study guide chapter describes common diseases
transmitted by pets that primary care physicians encounter and discusses your veterinary team's role in
educating pet owners about zoonotic diseases.

Chapter 2 - Communication Failures: The Scope of the Problem

In 1999, two students at the University of Wisconsin School of Veterinary Medicine surveyed hundreds of
Wisconsin veterinarians and primary care physicians to determine how frequently each encountered
zoonotic diseases in their respective practices, how often they communicated with one another, and what
role physicians think veterinary practices should play in zoonotic disease prevention.2 The study found:

• Surveyed physicians and veterinarians indicated that they rarely communicated with one another.

• Veterinarians discussed zoonotic diseases with pet owners much more frequently than physicians,

although such discussions were described as weekly rather than daily events.
• Surveyed physicians felt veterinarians should assume responsibility for providing information

regarding zoonotic diseases to clients as well as physicians.

• The majority of surveyed veterinarians did not ask pet owners about their immune status.

• Surveyed physicians felt that veterinarians, rather than physicians, should provide information

about zoonotic diseases to immunocompromised pet owners.

Chapter 2 - It's Your Responsibility!

Veterinary healthcare teams should take an active role in helping to educate pet owners about zoonotic
diseases. This includes telling owners at every visit about the potential for the transmission of such diseases
from their pets to them or other household members and ways that owners can help minimize such risk. Ask
pet owners about the health status of other pets as sick pets at home may provide clues to help you
diagnose illnesses, particularly those with contagious zoonotic diseases.

Veterinary team members need to discuss zoonotic diseases and their prevention as part of every pet's
examination. Your discussion doesn't have to be lengthy, but it can and should be supplemented with written
handouts. Whenever you diagnose a potentially zoonotic disease in a household pet, tell clients about the
potential for disease transmission, regardless of the immune status of the pet owner. This is especially
important when pet owners indicate that they may be symptomatic as well.

Most common human zoonotic diseases:

1. Bite-related diseases
2. Gastrointestinal diseases
3. Skin-related diseases

Helminths aren't the only cause of common zoonotic diseases. A wide variety of infectious agents also are
culprits. Being familiar with common human zoonoses will help you prevent the spread of zoonotic diseases
to healthy and immunocompromised pet owners and also ensure that physicians quickly diagnose and treat
zoonotic diseases in people.

Chapter 2 - Primary Care Zoonoses

Although more than 100 zoonotic infections exist, primary care physicians see only a handful with regular
frequency, including bite-related, gastrointestinal, and skin-related diseases. As a general rule, zoonotic
 diseases are more commonly encountered in children because they may provoke biting or scratching, go
barefoot during warm weather, and may not wash their hands following handling household pets.3 Let's
review common bite-related, gastrointestinal, and skin-related zoonotic diseases that physicians see.

Chapter 2 - Animal Bites

More than 1 million animal bites occur each year in the United States, with half of them serious enough to
warrant medical evaluation and treatment. The majority of victims are children. Dogs are responsible for
80% of reported bites, cats for 10%, and the remainder secondary to household lizards, ferrets, rabbits, and
other small animals.4 Because ferrets are frequently allowed to roam freely in pet owners' homes and are
attracted to the scent of milk, severe facial injuries around the mouths of sleeping infants have been
reported. When a household dog or cat bites a pet owner, physicians often prescribe prophylactic antibiotics
because approximately 30% of cat bites and 6% of dog bites become infected. Why is the rate higher for
cats? Dog bites tend to cause tearing injuries, which can be more easily irrigated and debrided, while cat
bites usually produce deep puncture wounds, which are more likely to become infected. Infectious agents
cultured from animal bites include Pasteurella multocida, Staphylococcus aureus, Staphylococcus
intermedius, as well as anaerobic streptococci.4

Given the 100% fatality rate associated with human rabies, most public health authorities recommend giving
people a post-exposure rabies prophylaxis regimen of rabies immunoglobulin and a five-dose course of
rabies vaccine when stray or unimmunized pets bite a human, especially when the bite is not provoked. As a
veterinary professional, you should cooperate with local public health authorities to expedite the diagnosis of
the biting animal.

You can help prevent dog bites in households with young children with pet-selection counseling. Caution
clients with young children about adopting aggressive breeds such as pit bulls, Doberman pinschers,
Chihuahuas, chows, bullterriers, rottweillers, and German shepherds. Encourage parents to teach their
children to avoid stray animals, supervise young children when they play with pets, and avoid behaviors that
may appear threatening to household pets. When bites occur, people may initially contact your veterinary
hospital for advice on wound management, but advise them to contact their physicians regarding wound
care, evaluation and prophylaxis, and consideration of rabies post-exposure prophylaxis depending on the
circumstance of the bite.5

Chapter 2 - Gastrointestinal Illnesses

The most frequently diagnosed human gastrointestinal infection transmitted by pets is caused by
the bacteria Campylobacter
1. Ingesting contaminated food or water
2. Exposure to feces of infected humans or animals

Campylobacter jejuni, which is caused by a microaerophilic gram-negative rod, is the most frequently
diagnosed human gastrointestinal bacterial infection transmitted from pets. Campylobacter infections result
from the ingestion of contaminated food or water or from exposure to feces of infected humans or animals,
including household dogs, cats, birds, and hamsters. Common symptoms of infection in pet owners include
diarrhea (often bloody), abdominal pain, and fever. Campylobacter gastroenteritis typically lasts 1 to 2 days
but approximately 20% of those affected may have a relapse or prolonged illness.6

Figure 1 - Children may be at high risk for exposure to zoonotic disease.

Another common pet transmitted human gastrointestinal infection is non-typhoidal Salmonella, which causes
diarrhea, fever, and abdominal cramps in humans. The major reservoirs of non-typhoidal Salmonella
organism are animals, including poultry, livestock, reptiles, and pets. Although most frequently transmitted
from contaminated food or water, occasional transmission occurs from infected humans as well as from
pets, especially reptiles such as iguanas, turtles, and geckos. For this reason, reptile owners must be
reminded not to wash their pets in the kitchen sink where food can be contaminated during preparation.
Attack rates for non-typhoidal Salmonella infections are highest in children and the elderly. Following an
infection, humans can shed bacteria in stools for 12 weeks or longer, and antimicrobials can prolong
excretion. Antibiotic therapy is usually not indicated for humans with uncomplicated gastroenteritis caused
by non-typhoidal Salmonella, but is indicated for those with an immunosuppressive illness.7

Figure 2 - Cryptosporidiosis or Giardia infection in

immunocompromised people may be deadly.

Cryptosporidiosis in immunocompetent humans produces frequent, non-bloody watery diarrhea. Caused by

Cryptosporidium parvum, a spore-forming coccidian protozoan, infection also can cause abdominal cramps,
vomiting, and fever, and may be confused with viral gastroenteritis in children. Although the most common
mechanism of infection is transmission of cryptosporidiosis from one person to another, infection may be
transmitted from either symptomatic or asymptomatic pets, including rodents and reptiles. When
immunocompromised humans are infected with cryptosporidiosis, they may experience chronic severe
diarrhea, and some cases are associated with dehydration, malnutrition, and death.8

Although Giardia lamblia is a recognized cause of diarrhea in dogs and cats, as well as in humans, many
debate whether Giardia infections represent true zoonoses. Growing evidence suggests that Giardia can be
transmitted from pets to pet owners and vice versa.9 Physicians and veterinarians often report a
symptomatic pet in households where multiple family members have diarrheal illness due to Giardia. In such
cases, pets as well as human family members need treatment to eradicate Giardial disease from the
household.9

Be aware that these gastrointestinal illnesses often aren't contracted from household pets, rather from
contaminated food, water, or other infected individuals. Symptomatic pet owners can easily transmit these
agents to pets, although most may be unaware that this is possible. This is a situation where asking pet
owners about their health can facilitate the diagnosis and treatment of illnesses in pets!

Chapter 2 - Zoonotic Diseases of the Skin

Skin-related zoonoses:
1. Ringworm
2. Scabies
3. Cutaneous larva migrans ("creeping eruption")

Several zoonotic diseases may give pet owners a variety of rashes. Researchers estimated that more than
25% of human ringworm, called tinea capitus and corporus, is contracted from infected cats and dogs,
caused by the organisms Trichophyton and Microsporum. When ringworm is diagnosed in a pet owner, all
household dogs and cats need to be examined and treated when indicated to prevent re-infection. Although
the majority of human scabies is caused by the mite, Sarcoptes scabiei, subspecies hominis, occasionally
Sarcoptes scabiei, subspecies canis, is acquired from dogs. A typical rash from the canis subspecies in
 humans is papular, and it lacks the tracts that are usually seen in the rash secondary to the hominis
subspecies. In dogs, the canis mite produces a skin infection called mange, and these dog owners should
be advised to seek medical attention if they develop any suspicious rashes.10

Figure 3 - Cutaneous larva migrans ("creeping eruption").

Hookworms of dogs and cats may cause cutaneous larva migrans. Infection occurs most often in the
southeastern United States and among children because their play habits put them in contact with
contaminated soil and they may handle infected young pets. Skin lesions consist of raised red serpentine
tracts and cause severe itching. A hookworm produces an anticoagulant in its saliva so the host's blood
does not clot at the site where the hookworm attaches. If the hookworm moves from one site to reattach
itself to another, the first site may continue to bleed, sometimes seriously. In severe cases, larvae migrate
through the skin and enter deeper tissues, causing painful muscles and lung disease. Hookworm infections
in people also may cause visceral larva migrans.

Most pet owners don't know that hookworm infections can be transmitted from pets to people, so you play
an important role in prevention by recommending routine deworming of pets and advising parents when a
pet is diagnosed with hookworm or other roundworm infections to take appropriate precautions.

The Centers for Disease Control and Prevention (CDC) suggests that you discuss the following
with all dog and cat owners11:

• Types of intestinal helminths that infect dogs and cats and the illnesses they cause in

pets, including anemia, diarrhea, lethargy, dry or dull haircoat, and stunted growth in young

animals
• How intestinal helminths are transmitted to dogs and cats, with special emphasis on

helminths acquired through prenatal (Toxocara canis) and transmammary (Ancylostoma

caninum, Toxocara cati and, to a limited degree, T.canis) routes

• How ascarids and hookworms can cause problems in humans, especially children,

whose play habits and attraction to pets put them at increased risk
• How infection in both pets and people can be prevented by well-timed prophylactic

anthelmintic treatment of puppies and kittens and routine diagnostic examinations or periodic

preventive treatment of older pets

• How to collect and dispose of pets' feces, especially in areas where children play
 • How to keep children away from areas that may be contaminated by dogs or cats

infected with helminthes

Chapter 2 - Caring for Immunocompromised Pet Owners

Pet owners who have Human Immunodeficiency Virus (HIV) infections, or are receiving treatment for
cancer, are at high risk for contracting zoonotic diseases from their pets. Immunocompromised people may
develop more serious illnesses, and zoonotic diseases may even be life threatening. Because of the
enormous mental and physical benefits of companion animals for people with serious medical problems, you
need to counsel pet owners who are at risk for contracting zoonotic diseases.

The CDC offers helpful guidelines on pet ownership for immunosuppressed patients. These patients should
avoid adopting animals less than 6 months of age, especially those with diarrhea. A veterinary professional
should evaluate household pets with diarrhea promptly, including examining stool specimens for
Cryptosporidium, Salmonella, and Campylobacter. Patients should wash their hands after handling pets,
avoid pet feces, and keep away from animals with diarrhea. The risk of salmonellosis also makes reptiles a
poor pet choice for these patients. Talk with these patients about the potential risks of cat ownership, such
as toxoplasmosis and Bartonella infections, in addition to the risks of cryptosporidiosis, salmonella, and
campylobacteriosis. Risks are lower if an adopted cat is older than 1 year, not permitted to go outdoors, and
isn't allowed to hunt or eat raw or undercooked meat. Patients should avoid activities that may result in cat
scratches or bites, should wash cat bites promptly, and should not allow cats to lick open wounds. Good flea
control will further reduce the risk of Bartonella infection.12

Clients at high-risk for zoonosis:

1. Children
2. HIV or cancer patients
3. Persons with immune system diseases

Chapter 2 - Start Educating Clients Today

As a veterinary professional, your responsibilities extend well beyond the routine healthcare of household
pets. Zoonotic disease prevention and education should be a high priority. Routine deworming of young and
adult animals will help prevent helminth-related zoonotic diseases, and pet-selection counseling will help
families with young children avoid animal bite infections.

Your veterinary team can develop an educational program for staff members and pet owners and create a
system to identify clients at high risk for zoonoses. Lastly, when you diagnose a pet with an infection that
has the potential to be transmitted to family members, inform pet owners immediately to facilitate the timely
diagnosis of zoonotic diseases by physicians.

Chapter 2 - Action Step: Use Role-Playing to Improve Your Communication Skills

During your next staff meeting, invite a pharmaceutical representative to discuss zoonotic diseases and
what messages you need to communicate to clients. To help every member of your veterinary team talk
confidently about zoonotic disease, try these role-playing exercises during a staff or department meeting.
One person pretends to be the client while the other plays the part of a veterinary staff member. After the
exercise, ask staff members to give feedback on effective communication techniques and ways to make the
conversation even stronger next time.

• You diagnose hookworms in an adult dog. How will you explain the zoonotic risks to family

members?
• A client undergoing cancer treatment brings her cat to your hospital for an annual examination and
 vaccinations. How will you explain the risk of zoonotic diseases?
• A mother with two toddlers brings a 4-week-old puppy for its first veterinary visit. What diagnostic

tests and preventive treatments will you recommend? What will you tell the mother about protecting her

children from zoonotic diseases?

• You diagnose Giardia in a puppy. What questions will you ask the client to see whether this

zoonotic disease has spread to other household members, including people and pets? What are your

clinic's medical protocols for the prevention and treatment of Giardia?

Chapter 2 - Review: Zoonotic Diseases, The Human Health Perspective

• When talking with their respective clients, physicians and veterinarians must communicate the

potential for transmission of infectious agents from pets to pet owners, and more rarely from owners to

pets. Because more than 40% of immunosuppressed individuals, such as those with Acquired

Immunodeficiency Syndrome (AIDS) or undergoing cancer treatment, own a companion animal, the

prevention of zoonotic disease is just as important as its timely diagnosis.1

• Discuss zoonotic diseases and their prevention as part of every pet's examination. Also ask pet

owners if the immune status of any household member has changed since their pets were last seen and

document this information in pets' medical records. Whenever you diagnose a potentially zoonotic

disease in a household pet, tell clients about the potential for disease transmission, regardless of the

immune status of the pet owner.

• Although more than 100 zoonotic infections exist, primary care physicians see only a handful with

regular frequency, including bite-related, gastrointestinal, and skin-related diseases. As a general rule,

zoonotic diseases are more commonly encountered in children because they may provoke biting or

scratching, go barefoot during warm weather, and may not wash their hands following handling

household pets.3
• When a household dog or cat bites a pet owner, physicians often prescribe prophylactic antibiotics

because approximately 30% of cat bites and 6% of dog bites become infected. Dog bites tend to cause

tearing injuries, which can be more easily irrigated and debrided, while cat bites usually produce deep

puncture wounds, which are more likely to become infected.

• Campylobacter jejuni, which is caused by a microaerophilic gram-negative rod, is the most

frequently diagnosed human gastrointestinal infection transmitted from pets. Campylobacter infections

result from the ingestion of contaminated food or water or from exposure to feces of infected humans or

animals, including household dogs, cats, birds, and hamsters.

• Growing evidence suggests that Giardia can be transmitted from pets to pet owners and vice

versa.9 Physicians and veterinarians often report a symptomatic pet in households where multiple family
 members have diarrheal illness due to Giardia.
• Researchers estimated that more than 25% of human ringworm, called tinea capitus and corporus,

is contracted from infected cats and dogs, caused by the organisms Trichophyton and Microsporum.

When ringworm is diagnosed in a pet owner, all household dogs and cats need to be examined and

treated when indicated to prevent re-infection.

• Hookworms of dogs and cats may cause cutaneous larva migrans. Infection occurs most often in

the southeastern United States and among children because their play habits put them in contact with

contaminated soil and they may handle infected young pets. Skin lesions consist of raised red serpentine

tracts and cause severe itching. Hookworm infections in people also may cause visceral larva migrans.

Symptoms include pneumonia, chest pains, and coughing.

• Immunosuppressed patients should avoid adopting animals less than 6 months of age, especially

those with diarrhea. A veterinary professional should evaluate household pets with diarrhea promptly,

including examining stool specimens for Cryptosporidium, Salmonella, and Campylobacter. Patients

should wash their hands after handling pets, avoid pet feces, and keep away from animals with diarrhea.

Chapter 2 Pre-Test Answers:

1. When discussing zoonotic diseases with clients, you should ask pet owners if the immune status of any
household member has changed since their pets were last seen. True
2. Researchers estimate that more than 45% of human ringworm is contracted from infected cats and dogs.
False
3. Growing evidence suggests that Giardia can be transmitted from pets to pet owners and vice versa. True
4. When a household dog or cat bites a pet owner, physicians often prescribe prophylactic antibiotics
because approximately 30% of cat bites and 50% of dog bites become infected. False
5. Zoonotic diseases are more commonly encountered in children because they may provoke biting or
scratching, go barefoot during warm weather, and may not wash their hands following handling household
pets. True

Chapter 3 - Larva Migrans from Pets and Wildlife

As a result of the large number of infected dogs, cats, and raccoons around people, the most common
causes of zoonotic larva migrans in humans are Toxocara canis, T. cati, Baylisascaris procyonis, and
Ancylostoma species. Learn how you can take a preventive approach to treating pets and helping families
understand these zoonotic parasites.
By Kevin R. Kazacos DVM, PhD

Test Your Current Knowledge

Do you know the most common zoonotic parasites transmitted from pets to people? Before
studying this chapter, take this pre-test to check your knowledge of helminth parasites. Answers
can be found in the Chapter Review.
1. You should deworm puppies for ascarids and hookworms beginning at 2 weeks of age, with
additional treatments at 4, 6, and 8 weeks of age. True or False?
2. Toxocara canis is a common cause of cutaneous larva migrans in children in the United
States. True or False?
3. Puppies acquire Toxocara canis primarily by transplacental transmission; consequently, nearly
all puppies are born infected with T. canis. True or False?
4. Risk factors for contracting human toxocariasis, particularly by children, include contact with
puppies or soil contaminated with T. canis eggs. True or False?
5. Infected puppies can shed tremendous numbers of eggs in their feces, beginning as early as 6
weeks of age. True or False?
Many helminth parasites of pets and wildlife can cause zoonotic infection when people come into contact
with the parasites' infective stages.1-7 In some cases, people are infected directly by ingesting infective
eggs or through skin penetration by infective larvae. In other cases, people are infected indirectly by
ingesting larvae in food items or through the bites of arthropod vectors. Ascarids and taeniid tapeworms,
which are acquired through ingestion of infective eggs, and hookworms and Strongyloides species, which
are acquired by skin penetration, are zoonotic helminths of greatest concern to veterinary healthcare
teams.7 Ascarids and hookworms are particularly important because they commonly cause larva migrans in
humans.

The prolonged migration and persistence of helminth larvae in the organs and tissues of people and animals
is called larva migrans.1-3 Larva migrans is separated clinically and pathologically by the organ system
involved, into visceral, ocular, neural, and cutaneous larva migrans.7,8 Because of the large number of
infected dogs, cats, and raccoons around people, the most common causes of zoonotic larva migrans in
humans are Toxocara canis, T. cati, Baylisascaris procyonis, and Ancylostoma species. Let's review the
disease aspects and prevention of each of these causes of zoonotic larva migrans.

Chapter 3 - Toxocariasis

Sources of zoonotic infection:

Contaminated objects or areas
- Soil
- Hands
- Toys
- Plants
- Sandboxes

Figure 1 - Puppy with heavy Toxocara canis infection,

showing typical "pot-bellied" appearance.

Toxocara canis, the common ascarid of dogs, is the most common cause of zoonotic visceral larva migrans
and ocular larva migrans worldwide, and it also can produce neural larva migrans in severe cases. People
also can become infected with T. cati, but this occurs less often. Infection with Toxocara occurs when
people, primarily children, ingest infective eggs from contaminated areas or items, including soil, hands, and
fomites such as toys. Sources of infection include homes, parks, playgrounds, and public places
contaminated by dogs or cats.3,7

Despite the widespread availability of effective anthelmintics, a high prevalence of T. canis still exists in the
dog population in North America and worldwide. Toxocara infections are most common in puppies less than
3 to 6 months old, and prevalences greater than 90% and approaching 100% have been reported in puppies
less than 3 months of age.9,10 Adult dogs also can be a source of infection.10-14 A national survey found
that 15% of dogs overall and 10.6% of dogs 3 to 7 years of age were infected with T. canis.14 Previous
studies that involved nearly 42,000 dogs worldwide and 6,621 dogs in North America also showed an overall
prevalence of T. canis of 15%.9,10
Toxocara canis can be transmitted to dogs in a variety of ways.2,13 Puppies acquire it from their mothers by
transplacental transmission; consequently, nearly all puppies may be born infected with T. canis.7,9-13
Additionally, some larvae are acquired postnatally in the mother's milk, and puppies are very susceptible to
infective eggs. Infected puppies can shed tremendous numbers of eggs in their feces, beginning as early as
2 1/2 to 3 weeks of age. Nursing mothers also are susceptible, and acquire late-stage larvae from ingesting
their puppies' feces. When an older puppy or adult dog ingests infective eggs, the larvae typically undergo
somatic migration and enter various tissues, where they lie dormant until becoming reactivated in the
pregnant female. Even in older dogs, some larvae undergo hepatic-tracheal migration and mature into adult
worms; thus mature dogs also may be a source of environmental contamination.7

Figure 2 - Infective Toxocara cati egg recovered from the

sandbox of a child with visceral larva migrans.

The extent of environmental contamination possible with Toxocara, mostly by puppies, is striking. One adult
T. canis female can produce more than 100,000 eggs per day. Heavily infected puppies may pass 100,000
eggs per gram of feces, shedding millions of eggs into the environment daily.9-13 A Purdue University study
found that two puppies with low worm burdens still shed an average 10,983 T. canis eggs per gram of feces,
amounting to 294,454 eggs per defecation. In one week, these puppies shed an estimated 20,545,459 eggs,
extensively contaminating a 2,800-square-foot backyard.7 At suitable temperatures, Toxocara eggs develop
to infectivity in 2 to 4 weeks and can remain viable in the soil for years (Figure 2). Because Toxocara eggs
are very sticky, they will adhere to various objects, increasing their spread and eventual transmission to
other animals and human beings.

Figure 3 - Toxocara canis larval granuloma in

a patient with visceral larva migrans.

When people ingest infective eggs, the larvae hatch in the small intestine. Larvae then penetrate the
intestinal wall and migrate to the liver and lungs. From the lungs, larvae enter the systemic circulation and
distribute throughout the body, migrating into a variety of tissues.8,11 Toxocara larvae measure about 400
µm long, and their migration causes mechanical damage, tissue necrosis, and intense eosinophilic
inflammatory reactions.8 Migration continues until the larvae become encapsulated in eosinophilic
granulomas, in which the larvae may survive for years. Clinical signs vary and depend on the intensity and
frequency of infection, the distribution of larvae in the body, and the intensity of the ensuing inflammatory
response. Inflammatory reactions are directed against larval excretory-secretory antigens, which consist of
enzymes, cuticular proteins, and metabolic wastes released by the larvae during migration.7,8

Large numbers of Toxocara larvae migrating in internal organs produces the condition called visceral larva
migrans, which may be acute or chronic.2,3,7-9,11-13 Children 1 to 4 years old who exhibit pica or
geophagia are most commonly affected, with an average patient age of about 2 years. Children may ingest
a large number of eggs at one time or be repeatedly infected. Although rarely fatal, visceral larva migrans
can make children very sick and the damage could affect them for years. The liver and lungs are the main
organs affected in visceral larva migrans. Affected children exhibit abdominal pain, fever, hepatomegaly,
respiratory signs, and high eosinophilia. Inflammatory reactions result in the trapping of large numbers of
Toxocara larvae in internal organs, particularly the liver. Fatalities usually result from massive invasion of the
brain or heart, or from an exaggerated immune response.3,9,11-13 Visceral larva migrans is typically treated
with a combination of anthelmintic drugs and corticosteroids.

Figure 4 - Enucleated eye from a patient with toxocaral

endophthalmitis, showing large retrolental mass associated
with funnel-shaped retinal detachment. (AFIP Neg 53-18355).

Ocular larva migrans results from larval invasion of the eye via the systemic circulation.2,3,7-9,11-13
Typically, the patient is a child or young adult who develops unilateral ocular disease. They have no history
of pica or geophagia and no evidence of visceral larva migrans. Most cases of ocular larva migrans result
from infection with few larvae, as suggested by low or absent Toxocara-specific antibody titers and
eosinophilia. Migration of a single larva into the eye produces ocular damage, inflammation, and loss of
vision. Some patients are asymptomatic and the infection is detected during a routine eye exam. Other
patients may have strabismus, decreased vision, or leukocoria.3 On ocular examination, retinochoroiditis,
vitritis, papillitis, granulomatous masses, or endophthalmitis ± retinal detachment may be seen. Ocular larva
migrans is treated with anthelmintics and steroids, and if a larva is seen in the retina on ophthalmoscopic
examination, it can be killed using laser photocoagulation.7

Most cases of human toxocariasis are asymptomatic or clinically inapparent.3,11-13 In some children and
adults, the infection is covert and manifested as a variety of nonspecific symptoms, all in the presence of
elevated Toxocara antibody titers.7 Although the true incidence of infection is not known, a high level of
seropositivity to Toxocara exists in human populations worldwide. When 8,457 people in the United States
were tested, an overall Toxocara seroprevalence of 3% was found.9 Infection rates are higher among lower
socioeconomic groups and rural residents, reaching 23% or higher in some studies.2 In a group
ophthalmology practice in Atlanta, Georgia, 41 cases of toxocaral ocular larva migrans were diagnosed
during an 18-month period, accounting for 37% of all retinal disease seen in children.2

As a veterinary healthcare provider, you need to realize that Toxocara is still common in the dog population
in North America. Risk factors for contracting toxocariasis, particularly by children, include contact with
puppies or soil contaminated with T. canis eggs. Your intervention could limit or help prevent human
infection from these or other sources.

Types of Larval Migrans:

 - Visceral
- Ocular
- Neural
- Cutaneous

Chapter 3 - Hookworms (Ancylostoma species)

Figure 5 - Cutaneous larva migrans caused by hookworms.

(Photo provided by Dr. Allen Paul, University of Illinois, Urbana, IL)

Hookworms are common intestinal helminths of dogs and cats throughout the world. In a nationwide survey
in the United States, 19% of dogs were found infected with Ancylostoma caninum.14 Infective larvae of the
cat and dog hookworms, A. braziliense and A. caninum, penetrate and migrate within the skin of humans.
This produces a condition called cutaneous larva migrans or "creeping eruption".1,3,5,15 Hookworm larvae are
typically found in damp, sandy soil, including shady areas under bushes, crawl spaces under houses and
porches, in sandboxes, and on beaches. The risk for human infection is associated with contact with
contaminated areas containing the larvae. Ancylostoma braziliense occurs in dogs and cats in coastal
regions of the southeastern United States and tropics. Travelers returning from tropical vacations are being
diagnosed with cutaneous larva migrans with increasing frequency. Although cutaneous larva migrans is an
annoying condition that is intensely pruritic, it is usually self-limiting and easily treated.

The zoonotic importance of A. caninum increased greatly after an adult worm was recovered from the
intestine of an Australian patient with eosinophilic enteritis in 1988.15 By 1994, more than 200 cases had
been diagnosed clinically and serologically in northeastern Australia, and solitary adult A. caninum were
seen in at least 15 patients with eosinophilic enteritis.4,15 Recently in the southeastern United States, two
probable cases were diagnosed in children15 and it is likely that more cases will be identified wherever A.
caninum is found. Eosinophilic enteritis may be acute or chronic and clinical signs include recurrent
abdominal pain, small bowel thickening, eosinophilia, elevated IgE levels, and foci of inflammation or
ulceration in the distal ileum and colon.4,15 Eosinophilic enteritis due to A. caninum is easily treated with
anthelmintics such as mebendazole.

Chapter 3 - Raccoons and Baylisascariasis

Baylisascaris procyonis, the raccoon ascarid, is the most common and widespread cause of clinical larva
migrans in animals. The parasite typically produces clinical neural larva migrans, resulting in fatal or severe
neurologic disease (Figures 6 and 7).7,8,16,17 Baylisascaris procyonis migration has killed more than 90
species of birds and mammals, including humans, in North America.17
Figure 6 - Gray squirrel with Baylisascaris procyonis encephalitis.

Figure 7 - Baylisascaris procyonis larva (1,762 µm x 73 µm)

recovered from the brain of a pet parrot with fatal encephalitis.

Raccoons are well adapted to living and interacting with people in urban and suburban areas. Raccoons are
commonly infected with B. procyonis, with prevalence rates as high as 68% to 82% in different areas of the
United States.17 Similar to the situation with T. canis in dogs, infected raccoons can shed millions of B.
procyonis eggs per day in their feces. Raccoons typically establish communal latrines at the bases of trees
or on raised horizontal structures, including large logs, stumps, woodpiles, and even decks and rooftops.
Various small mammals and birds become infected with B. procyonis by foraging for undigested seeds in
raccoon feces at these latrines.17

Figure 8 - Cross section of Baylisascaris procyonis larva in

the brain of a child with fatal encephalitis.

When people or animals are infected with B. procyonis, the larvae undergo aggressive somatic migration,
entering various internal organs and tissues, including the brain and eyes.8,16,17 Size is a key factor in their
pathogenicity, and the larvae grow considerably following infection, reaching a final size of 1,500-2,000 µm
long. Larvae that enter the brain can cause significant damage, leading to clinical neurologic disease. The
severity and progression of clinical disease depends on the number of eggs ingested, the number of larvae
entering the brain, and the location and extent of migration damage and inflammation.8,16,17 Encephalitis
due to B. procyonis has been diagnosed in 11 young children and a 17-year-old with fatal or severe
neurologic disease, and the condition is suspected in another child and in a 21-year-old. The parasite also is
a well-known cause of ocular larva migrans in humans, causing lesions and clinical disease similar to
toxocaral ocular larva migrans.7,17

Figure 9 - Baylisascaris procyonis larva migrating in the retina

of a man with ocular larva migrans. Note the larva just left of
center. (Courtesy of Dr. B. Katz, San Francisco, CA).

The overall seroprevalence of baylisascariasis in people has not been investigated, so it is unknown just
how common human infection is. As with toxocariasis, however, clinically normal individuals have been
found to be seropositive for Baylisascaris, indicating that low-level, asymptomatic infection occurs.7 Thus, B.
procyonis may cause a wide spectrum of human disease, depending on the level of infection and particular
organ systems involved. Because the parasite is so widespread in raccoons and the likelihood of human
contact with raccoon feces is great, the risk of human infection with B. procyonis is considered to be
high.7,17 Researchers recently found that B. procyonis also can mature in domestic dogs, which is a clear
cause for concern.17 More than 24 dogs with intestinal infection with B. procyonis adults have been
identified in the midwestern United States. Several of these dogs had mixed infections with T. canis and/or
other intestinal helminths. Canine infection with B. procyonis is probably more common and widespread than
is presently known and deserves diagnostic vigilance by veterinary professionals. The indiscriminate
defecation habits of dogs would likely result in more widespread domestic contamination with the eggs of
this dangerous parasite, thereby increasing risk of human infection.7 Differentiation of B. procyonis and T.
canis eggs in dogs is important so appropriate treatment and control methods can be initiated promptly.
Baylisascaris eggs are ellipsoidal, brown, and contain a large single-celled embryo. They have a thick shell
with a finely granular surface. Baylisascaris eggs are smaller than the coarsely pitted eggs of Toxocara
species, and range in size from 63 to 88 µm by 50 to 70 µm.7,16,17 By comparison, T. canis eggs are about
85 to 90 µm by 75 to 80 µm, and T. leonina eggs, 75 to 85 µm by 60 to 75 µm.

Figure 10 - Baylisascaris procyonis (smaller) and Toxocara canis (larger)

eggs recovered by flotation from the feces of a dog infected with both.
Chapter 3 - Action Step: Developing Strategies for Prevention and Control

Prevention is clearly the key to protecting people from zoonotic helminths.7 Veterinary teams have a
responsibility to not only control these parasites in their patients, but also to work with other health
professionals to help protect children and other family members from infection. The three most important
issues concerning prevention of human infection are:

1. Educating the public about the health risks of zoonotic helminths.

2. Reducing environmental contamination with infective eggs and larvae from animal feces.

3. Limiting or preventing contact between children and contaminated environments.

Your public health program should include these proactive elements:7

• Educate people about health risks associated with contaminated environments.

• Implement strategic deworming of dogs, cats, and wild animals kept as pets.

• Reduce the number of stray dogs, cats, and nuisance wildlife.

• Enforce leash laws and fecal cleanup laws for dogs.

• Exclude dogs from playgrounds and park areas where children play.

• Keep children away from contaminated environments.

• Teach children to recognize and avoid raccoon latrines.

• Cover sandboxes when not in use.

• Wash hands after handling animals or having contact with their feces.

• Emphasize routine veterinary care of pets.

• Promote responsible pet ownership.

The Centers for Disease Control and Prevention (CDC) and the American Association of Veterinary
Parasitologists recommend deworming puppies for ascarids and hookworms, beginning at 2 weeks of age,
with additional treatments at 4, 6, and 8 weeks of age.7,18,19 Some recommend extending this biweekly
treatment regimen to 3 months of age.7,19

Because prenatal transmission of intestinal parasites doesn't occur in cats, treatment of kittens may begin at
6 weeks of age and be repeated at 8 and 10 weeks. Puppies and kittens should be dewormed even if fecal
examinations are negative. This ensures the removal of prepatent intestinal worms before they begin
shedding eggs. A strategic deworming program begun early in life should continue with monthly treatments
until the pet is at least 6 months old, followed by a retreatment interval tailored to the individual animal or
situation. Several safe and effective anthelmintics are available, including monthly heartworm preventives
that treat and control intestinal nematodes in dogs and cats of appropriate age.7,18,19 For maximum
protection and control, strategic deworming should be combined with a program of environmental cleanup
and decontamination of contaminated areas.2,7

Zoonotic diseases are on the rise worldwide because humans are having increased contact with domestic
and wild animals. Along with other healthcare professionals, veterinary teams play a key role in providing
patient care and information to help prevent and combat zoonotic diseases. Through public education and
strategies designed to eliminate parasites and contaminated environments, veterinary teams can prevent
human infections with zoonotic helminths.

Chapter 3 - Review: Larva Migrans from Pets and Wildlife

• Many helminth parasites of pets and wildlife can cause zoonotic infection when people come into

contact with the parasites' infective stages.1-7 In some cases, people are infected directly by ingesting

infective eggs or through skin penetration by infective larvae. In other cases, people are infected

indirectly by ingesting larvae in food items or through the bites of arthropod vectors.
• The prolonged migration and persistence of helminth larvae in the organs and tissues of people

and animals is called larva migrans.1-3 Larva migrans is separated clinically and pathologically by the

organ system involved, into visceral, ocular, neural, and cutaneous larva migrans.7,8 Because of the

large number of infected dogs, cats, and raccoons around people, the most common causes of zoonotic

larva migrans in humans are Toxocara canis, T. cati, Baylisascaris procyonis, and Ancylostoma species.
• Infection with Toxocara occurs when people, primarily children, ingest infective eggs from

contaminated areas or items, including soil, hands, and fomites such as toys. Sources of infection include

homes, parks, playgrounds, and public places contaminated by dogs or cats.3,7

• Toxocara infections are most common in puppies less than 3 to 6 months old and prevalences

greater than 90% and approaching 100% have been reported in puppies less than 3 months of age.9,10

Adult dogs also can be a source of infection.10-14

• Toxocara canis can be transmitted to dogs in a variety of ways.2,13 Puppies acquire it from their

mothers by transplacental transmission; consequently, nearly all puppies are born infected with T.

canis.7,9-13 Additionally, some larvae are acquired postnatally in the mother's milk, and puppies are very

susceptible to infective eggs.

• Children affected with visceral larva migrans may have abdominal pain, fever, hepatomegaly,

respiratory signs, and high eosinophilia. Migration of a single larva into the eye produces ocular damage,

inflammation, and loss of vision. In some children and adults, toxocariasis is covert and manifested as a

variety of nonspecific symptoms.7

• Hookworms are common intestinal helminths of dogs and cats throughout the world. Hookworm

larvae are typically found in damp, sandy soil, including shady areas under bushes, crawl spaces under

houses and porches, in sandboxes, and on beaches.

• Infective larvae of the cat and dog hookworms, A. braziliense and A. caninum, penetrate and

migrate within the skin of humans. This produces a condition called cutaneous larva migrans or "creeping

eruption."1,3,5,15 Ancylostoma caninum larvae may also enter and develop in the human intestine,

producing eosinophilic enteritis.

• Baylisascaris procyonis, the raccoon ascarid, is the most common and widespread cause of clinical

larva migrans in animals. The parasite typically produces clinical neural larva migrans, resulting in fatal or

severe neurologic disease,7,8,16,17 but it also is a well-known cause of ocular larva migrans.

Baylisascaris procyonis also can mature in domestic dogs, which then become another source of
 environmental contamination.

Chapter 3 Pre-Test Answers:

1. You should deworm puppies for ascarids and hookworms beginning at 2 weeks of age, with additional
treatments at 4, 6, and 8 weeks of age.True
2. Toxocara canis is a common cause of cutaneous larva migrans in children in the United States. False
3. Puppies acquire Toxocara canis primarily by transplacental transmission; consequently, nearly all puppies
are born infected with T. canis.True
4. Risk factors for contracting human toxocariasis, particularly by children, include contact with puppies or
soil contaminated with T. canis eggs.True
5. Infected puppies can shed tremendous numbers of eggs in their feces, beginning as early as 6 weeks of
age. False

Glossary of Terms

Zoonosis - Any disease that may be passed from animals to humans, plural - zoonoses, adjective -
zoonotic

acute - having a rapid onset and following a short but severe course

ambivalent - uncertain or unable to decide what course to follow

ancylostomiasis - infection by hookworms of the Ancylostoma species which may cause cutaneous larva
migrans (CLM) in humans

Ancylostoma braziliense - a specific type of hookworm commonly found in both dogs and cats

Ancylostoma caninum - a specific type of hookworm commonly found in dogs

anthelmintic - an agent that destroys or causes the expulsion of parasitic intestinal worms

antibodies - protein molecules produced by the immune system for defense

anticoagulant - a substance that prevents the clotting of blood

antimicrobials - a substance that kills microorganisms (such as bacteria) or suppresses their multiplication
or growth

arthropod - invertebrate having paired jointed limbs and a segmented body with an exoskeleton (i.e.,
crustaceans, arachnids, insects, myriapods)

ascarid - a type of intestinal worm that is sometimes referred to as roundworm (i.e., Toxocara canis,
Toxascaris leonina)

asymptomatic - having no symptoms of illness or disease

Bartonella - a type of gram-negative bacteria, order Rickettsiales

Baylisascaris procyonis - an ascarid (roundworm) of raccoons

blood serum - the clear liquid that separates from blood upon clotting

Bordetella bronchiseptica - gram-negative aerobic bacteria that infect the respiratory tract, resulting in a
condition commonly referred to as kennel cough
Campylobacter jejuni - gram-negative bacteria that resemble small, tightly coiled spirals; known to cause
intestinal disease

campylobacteriosis - an infection caused by the bacterium Campylobacter

cecum - the cavity in which the large intestine begins and into which the ileum opens

chronic disease - any disease that is long lasting and recurrent or characterized by long suffering

coccidia - a subclass of parasitic protozoa that is commonly found in the intestinal tract and, depending on
the species, other organs such as the liver

colonoscopy - an examination of the colon using visual tools

corneal opacity - the clouding or reduction of light passing through the clear part of the eye, the cornea

corticosteroids - a group of synthetic hormones used to suppress typical immune system response

creeping eruption - a common name for cutaneous larva migrans (CLM)

cryptosporidiosis - an infection caused by the internal parasite Cryptosporidium parvum

Cryptosporidium parvum - a small intestinal parasite which commonly causes infection in

immunocompromised persons

cutaneous larva migrans (CLM) - the human condition that results from the migration of hookworm larvae
in the skin; also called "creeping eruption"

cutaneous - of, relating to, or affecting the skin

cuticular - pertaining to the cuticle, or external protective membrane of worms

dipylidiasis - infection with Dipylidium caninum

Dipylidium caninum - a tapeworm, found in dogs and cats, whose larval stage lives in fleas

Dirofilaria immitis - a type of internal worm, commonly referred to as heartworm, that typically infects dogs
and cats; the adult stage resides in the heart and pulmonary arteries

distension - a swollen appearance that is caused by pressure from within

Echinococcus granulosus - a small tapeworm of dogs,wolves and sometimes cats

Echinococcus multicularis - a tapeworm that, in its adult form, parasitizes foxes, wild rodents and sometimes
humans

encephalitis - inflammation of the brain

endophthalmitis - inflammation involving the ocular cavities and their adjacent structures

enteritis - inflammation of the intestinal tract, especially of the small intestine

enterocolitis - an inflammation of both the small intestine and the colon

enzootic - affecting animals in a particular geographic area

enzymes - proteins that catalyze chemical reactions of other substances without being destroyed

eosinophilic - characterized by the presence of a large amount of white blood cells

fecal flotation - a laboratory method using solutions to concentrate and separate eggs of parasites from
fecal debris

flatworm - any parasitic or nonparasitic worm having a soft, flat, bilaterally symmetrical body and no body
cavity

foci - a center of interest or activity

fomite - an inanimate object or substance that is capable of transmitting infectious organisms from one
individual to another

gastrointestinal - of or relating to the stomach and intestines

geophagia - the practice of eating dirt or clay

Giardia lamblia - a specific type of protozoan parasite that inhabits the intestines of animals and people

gonadectomy - the removal of ovaries or testes; spaying; neutering

gram-negative - a quality of bacteria; gram-negative bacteria cannot be stained for inspection under a
microscope or they lose their color in alcohol

gram-positive - a quality of bacteria; gram-positive bacteria can be stained for inspection under a
microscope or they do not lose their color in alcohol

granuloma - a chronic, inflamed lesion comprised of large numbers of many different types of cells

gravid - carrying developing young or eggs

helminth - a parasitic worm

hepatic - acting on or occurring in the liver

heptomegaly - enlargement of the liver

hookworm - a type of intestinal parasitic blood-sucking worm characterized by hooked mouthparts which
are used to attach to the intestinal wall of the host

hydatid cyst - a cyst formed in the liver, or, less frequently, elsewhere, by the larval stage of Echinococcus

IgE - class of immunoglobulin associated with helminth infections

immunocompetent - having the normal bodily capacity to develop an immune response

immunocompromised - a condition in which the immune system is not functioning normally

immunodeficiency - inability to mount a normal immune response

immunoglobulin - a specific protein substance that is produced by plasma cells to aid in fighting infection

immunosuppressed - condition of having a lowered resistance to disease

lactogenic - of or pertaining to milk

laparotomy - surgical incision into the abdominal wall

larva - an immature worm that has hatched from its egg but is not yet a mature adult (pl.- larvae)

larva migrans - a human condition caused by the migration of roundworm or hookworm larvae inside the
body

laser photocoagulation - a treatment which uses a laser to destroy the larvae of parasitic worms
leukocoria - reflection from a white mass within the eye giving the appearance of a white pupil

mebendazole - an anthelmintic used to treat hookworm and roundworm infestations

microaerophilic - requiring oxygen at a level lower than that typically found in the normal sea-level
atmosphere of the earth

Microsporum - a number of fungi including the type known to cause ringworm

morbidity - sickness or disease

mucosal - pertaining to the lubricated inner lining of the mouth, nasal passages, or any lining which contains
mucous-secreting glands

Mycobacterium marinum - a specific bacterium often found in aquariums, swimming pools and diseased fish

necropsy - an examination of a dead body; autopsy

necrosis - death of cells or tissues through injury or disease, especially in a localized area of the body

nematode - any of several worms with unsegmented, cylindrical bodies, often narrowing at each end, and
including parasitic forms such as hookworms and ascarids (roundworms)

neural - of or relating to a nerve or the nervous system

neural larva migrans (NLM) - the human condition that results from the migration of ascarid (roundworm)
larvae in the body's internal organs

ocular - of, relating to, or affecting the eye

ocular larva migrans (OLM) - the condition that results from the migration of ascarid (roundworm) larvae to
the eye

opthalmoscopic - relating to examination of the interior of the eye

papillitis - inflammation of any of the projections occurring in various animal tissues and organs such as
taste buds on the tongue

papular - related to papules, small, solid elevations of the skin

parasite - an organism that grows, feeds, and is sheltered on or in a different organism while contributing
nothing to the survival of its host

parasiticide - a chemical or drug that destroys parasites

Pasteurella multodica - a specific type of rod-shaped gram-negative bacteria

patent - clearly apparent or obvious

pathogenicity - the quality of producing disease

peritonitis - an inflammation of the transparent membrane that lines the abdominal cavity in mammals and
covers most of the internal organs

pica - an abnormal craving or appetite for nonfood substances, such as dirt, paint, or clay

pneumonitis - inflammation of lung tissue

postnatal - of or occurring after birth, especially during the period immediately after birth
prenatal - existing or occurring before birth

prepatent - not yet clearly apparent or obvious; when pertaining to parasitic infection, the period elapsing
between infection and appearance of eggs or larvae from adults

prevalence - the total number of cases of a disease in a given population at a specific time

prevalent - widely or commonly occurring or existing

proclivity - a natural tendency or inclination; predisposition

prophylactic - defending or protecting from disease; preventive

protozoan - any of a large group of single-celled, usually microscopic, organisms

pruritic - severe or intense itching of the skin

pulmonary - of, relating to, or affecting the lungs

radiograph - another term for an x-ray film

rectum - The end portion of the large intestine that connects to the anus

retinochoroiditis - inflammation of the retina and middle part of the eye

ringworm - a fungal skin infection

roundworm - an unsegmented worm (sometimes referred to as an ascarid) with an elongated rounded body
pointed at both ends; usually free-living but can be parasitic

Salmonella - gram-negative bacteria known to cause intestinal disease and food poisoning

Sarcoptes scabiei - a mite that burrows into the skin and causes intense itching

serologic - relating to the science that deals with the properties and reactions of serums, especially blood
serum

seropositivity - showing positive results on serologic examination; showing a high level of antibody

seroprevalence - the rate at which a given population tests positive for particular antibodies

somatic - pertaining to the body

Staphylococcus aureus - a specific type of spherical gram-positive bacteria that tends to cause infection or
blood poisoning

Staphylococcus intermedius - a specific type of spherical gram-positive parasitic bacteria that tends to cause
infection or blood poisoning

steroids - see corticosteroids

strabismus - a visual defect in which one eye cannot focus with the other on an object because of
imbalance of the eye muscles, also called squint

streptococci - spherical gram-positive bacteria occurring in pairs or chains; commonly known to cause
tonsillitis

Strongyloides - a species of parasitic worm that commonly infects the intestines of mammals

symptomatic - exhibiting symptoms of a particular disease or infection

syndrome - a group of symptoms that collectively indicate or characterize a disease

systemic - relating to or affecting the entire body

taeniid - a family of tapeworm

tapeworms - ribbon-like flatworms that are parasitic in the intestines of humans and other vertebrates

terminal ileum - the end portion of the small intestine connected to the cecum

tinea capitis - a fungal scalp infection

tinea corporis - a fungal skin infection sometimes referred to as ringworm

titer - the concentration of a solution or amount

Toxocara canis - a specific type of ascarid (roundworm) commonly found in dogs

Toxocara cati - a specific type of ascarid (roundworm) commonly found in cats

toxocariasis - infection by roundworms of the Toxocara species which may cause visceral and ocular larva
migrans (VLM and OLM) in humans

Toxoplasma gondii - an adundant, widespread parasitic microorganism

toxoplasmosis - an acquired disease that may be characterized by fever, swollen lymph nodes, and lesions
in the liver, heart, lungs, and brain

Toxascaris leonina - a specific type of ascarid (roundworm) commonly found in both dogs and cats

tracheal - of or relating to the thin-walled tube (sometimes referred to as the windpipe) that descends from
the larynx to the bronchi and carries air to the lungs

transmammary - passing through or occurring across the mammary or milk glands

transplacental - passing through or occurring across the placenta

transverse colon - the part of the large intestine that extends across the abdominal cavity

Trichophyton - a specific type of fungus known to cause ringworm

Trichuris vulpis - a specific kind of whipworm, not known to be zoonotic

ulceration - an inflamed, often pus-producing lesion on the skin or internal mucous surface

Uncinaria stenocephala - a specific type of hookworm commonly found in both dogs and cats

visceral - pertaining to the soft internal organs of the body such as the intestines, liver, kidneys, heart and
lungs

visceral larva migrans (VLM) - the condition that results from the migration of ascarid (roundworm) larvae
into the body's internal organs

vitritis - inflammation of the clear gelatinous substance that fills the eyeball between the retina and the lens

whipworm - a slender, whip-shaped parasitic intestinal worm

.
Chapter 1 - Prevalences of Canine and Feline Parasites in the United States
Findings from this national survey can help you understand the prevalences of common intestinal parasites
and why you need to teach clients about monitoring pets for intestinal parasites and treating infected
animals promptly.
By Byron L. Blagburn MS, PhD

Test Your Current Knowledge

Do you know the prevalence of canine and feline parasites in your patients? Before studying this
chapter, take this pre-test to check your awareness of common intestinal parasites.
1. The highest prevalence of intestinal nematode parasites is in the Midwest region of the United
States. True or False?
2. Fecal flotation is not a consistently reliable method of recovering eggs of most tapeworm
species. True or False?
3. Toxocara canis, a common roundworm, is found with more frequency in dogs greater than 6
months old. True or False?
4. Dogs given a high level of care are known to harbor internal parasites. True or False?
5. The feline roundworm, called Toxocara cati, is rarely observed in North American internal
nematode parasite studies. True or False?
Parasitologists are often asked why parasites continue to be prevalent and important disease agents of
companion animals1,2, especially given the number and kinds of effective parasiticides available today. As
companies introduce newer, more effective products, veterinary professionals should reduce the prevalence
of parasites or eradicate them. Interestingly, if you compare surveys on prevalences of canine
gastrointestinal parasites, you won't see a dramatic or even demonstrable decline in prevalence rates for
common canine intestinal parasites. Evaluating prior surveys can be difficult for several reasons. Most
surveys were limited geographically to specific locations,3-32 or used either fecal3-11,14-18,20,23-25,30 or
necropsy12,13,19,21,22,26-29,31,32 procedures. Use of different techniques and procedures can lead to differing
results12 and makes comparing studies from different regions of the country difficult.

To address these problems and gain a current view of the prevalences of canine gastrointestinal parasites, a
team of researchers conducted a comprehensive national survey. To ensure meaningful results, they used a
consistently proven fecal flotation method to sample shelter dogs from all U.S. geographic regions. The
resulting survey wasthe first of its kind and provides helpful information on national and regional prevalences
of canine gastrointestinal parasites. These survey results will help you understand the risk of canine
gastrointestinal parasites in your community and places your clients might travel with their pets.

Chapter 1 - Survey Methods

Figure 1

Shelter personnel collected fecal specimens from dogs housed in animal shelters throughout the United
States (Figure 1). Researchers based sampling on the 1990 census, assuming the dog population correlates
closely with the human population. They instructed shelter personnel to sample only dogs that, to the best of
their knowledge, had not been treated with parasiticidal medications. Shelter personnel placed fresh
specimens in 120 ml plastic specimen cups with screw-cap lids. They put specimen cups in foam shipping
boxes containing artificial ice and shipped them overnight to an Auburn University laboratory.

Shelter personnel provided information on each dog's approximate age, breed, sex, and reproductive status
(i.e., male, female, intact, neutered, or unknown). Researchers stored specimens at 4°C until examined
using the centrifugal sucrose flotation procedure.33 All fecal stages of parasites were identified to genus or
to genus and species using established structural and morphometric criteria.33-36 Researchers attempted
to differentiate eggs of Ancylostoma caninum and Uncinaria stenocephala. The majority of eggs produced
by these two hookworms can be distinguished based on their sizes.37 Researchers did not attempt to
differentiate eggs of A. braziliense because of their reported similarity in size and shape to A. caninum.38
Researchers entered host signalment information and results of fecal flotation into a data-management
software program for summary and analysis (EpiInfo Version 6, Centers for Disease Control and Prevention,
Atlanta, GA). To present the data, researchers grouped states into four geographic regions: Northeast,
Southeast, Midwest, and West (Figure 2).
Figure 2

Chapter 1 - Survey Results

Researchers received 6,458 fecal specimens from animal shelters nationwide. You'll see the number of
samples from regions and states in Figure 1. Figures 2 through 4 show the national and regional
prevalences of single and multiple intestinal nematode infections. Looking at nationwide results for all dogs
surveyed (Figure 3), researchers observed eggs of the canine hookworm, Ancylostoma caninum, with the
greatest frequency (19.19%).

Figure 3

In this study, researchers determined prevalences of combinations of nematode infections by the

characteristics of individual parasites. For example, increased prevalences of combinations of T. canis and
A. caninum in young dogs reflect the propensity of these parasites to infect young dogs.

Researchers observed similar frequencies nationally and within three of the four regions for eggs of the
common roundworm, Toxocara canis (14.54%). Surprisingly, almost 36% (2,322) of all dogs sampled, and
nearly 52% (1,011) sampled from the southeastern United States, harbored at least one of the major
intestinal nematode parasites. Researchers did not anticipate the low national prevalence of Toxascaris
leonina (0.74%) and Uncinaria stenocephala (1.02%) observed in this study. Data from several previous
surveys using either fecal17 (in part) or necropsy12,13,19-22,25 examinations placed the prevalence of
these parasites higher than observed in this study. Occasionally, however, the prevalences of T. leonina or
U. stenocephala were lower than reported here.4,17(in part)

Prevalences of nematodes in individual regions mirrored trends observed nationally (Figure 4), except in the
southeast region, where prevalences of nematode parasites were considerably greater and in the western
region where prevalences were somewhat lower. These results are consistent with those reported
previously.9,10 Differences can be attributed to environmental factors, including soil type, elevation, climate,
ambient temperature, relative humidity, and the nature of the pet population (i.e., predominantly urban or
rural and well-cared-for dogs or poorly-cared-for dogs).18,24,25

Figure 4

Figure 5 shows influences of reproductive status on zoonotic parasite prevalences. To present this data,
researchers chose to combine intact female dogs with female dogs whose reproductive status was
unknown. Distinctly, intact female and male dogs were infected with T. canis and A. caninum or
combinations of these parasites with greater frequencies than either spayed female or neutered male dogs.
Although this trend was present for coccidia, it was less evident than for nematode parasites. Numerous
published studies have reported reduced prevalence of parasites in animals following
gonadectomy6,10,14,15 leading to considerable debate as to why this occurs. Some believe that
gonadectomy reflects a higher degree of owner stewardship or responsibility for pets.15 Therefore, pets that
have visited a veterinarian for a spay or neuter are more likely to be examined for parasites or to receive
parasiticidal medications, or they may live in environments that decrease their contact with parasites.
Others6 suggest that hormonal factors may play a role in parasite infections, citing that hormones are known
to affect the consequences of some parasitic infections in other hosts.45 Certainly reactivation and
maturation of sequestered somatic larvae of T. canis and A. caninum that might occur during pregnancy in
intact female dogs would be one source of these parasites not likely to affect spayed female dogs. Most also
agree that behavior associated with sex or mating, such as roaming, can increase the likelihood of contact
with environmental stages of parasites.6,15

Figure 5

These survey results reinforce the need to monitor dogs for intestinal parasites and to treat infected animals
promptly with effective parasiticides. The population of dogs sampled in this survey included a combination
of stray, lost, abandoned, or relinquished pets. As a result, parasite prevalences probably would have been
somewhat less in a well-cared-for dog population,3,4,5,6,10,14,15,18,25 and somewhat greater in strays or
poorly-cared-for dogs.9,19,22,24,26,30 However, even dogs given a high level of care are known to harbor
internal parasites.6,10,14,15,18

Remember that the shedding of parasites in feces can create heavily contaminated environments,
increasing the probability of reinfection of existing pets or infection of newly acquired ones. Veterinary
professionals also are seeing a growing concern over human infections with canine parasites, particularly
Ancylostoma spp., T. canis, and tapeworms.34,42 The high prevalence of parasites recorded in this study
indicate a need to continually monitor dogs for parasites of zoonotic significance and, if necessary, to treat
periodically to remove them.

Figure 6 shows prevalences of single and multiple infections of dogs with selected helminths and
coccidia according to the ages of dogs from which specimens were collected. Researchers
included coccidia because of the age-related prevalences of these parasites. As the data shows,
researchers recovered eggs of T.canis with more frequency from dogs less than 6 months old
when compared with dogs greater than 6 months old. Thereafter, prevalences diminished as
dogs aged, but were still demonstrable even in dogs over 7 years of age. Researchers expected
increased prevalence of T.canis in young dogs (less than 6 months) and comparably lower
prevalences in dogs greater than 6 months because of this parasite's proclivities for
transplacental infection of the fetus42 and to documented evidence of age-associated immunity in
adult dogs.43 Other studies reported similar trends in the prevalences of T.canis in dogs of
different ages.6,9,10,18,14,15

Infections with A.caninum occurred with similar frequencies in dogs of all ages. Despite reports of
age resistance to the canine hookworm, A.caninum,44 or reduced prevalences in older dogs,14,15
this and other prevalence studies did not observe striking reductions in prevalences of hookworm
infections in older dogs.6,9

Figure 6

Chapter 1 - Feline Parasite Prevalences

Compared to dogs, few internal parasite prevalence surveys have been conducted in cats in North America.
This can be attributed to several factors. First, except for those practices that are exclusively feline,
veterinarians see fewer cats than dogs on a regular basis. Secondly, cats comprise a smaller proportion of
animal control or shelter facilities than dogs, which makes it more difficult to acquire the number of cats
needed to obtain data comparable to what has been reported for dogs. These factors, along with the greater
difficulty in obtaining fecal specimens from cats for fecal surveys, have resulted in fewer parasite prevalence
surveys. Some information is available based on the few parasite surveys that have been published (Figure
7).
 Figure 7

The feline roundworm, called Toxocara cati, is the most commonly observed internal nematode parasite in
cats in North American surveys. As reported for T. canis in this survey, T. cati appears to parasitize cats in
most regions where surveys were conducted. Similar to T. canis, this can be attributed to the many ways in
which this parasite can infect cats.46 Cats can contract Toxocara cati several ways, including ingestion of
embryonated eggs; consumption of transport hosts such as mice, birds, cockroaches, and earthworms; and
transmammary transmission from mothers to kittens. Additionally, it's important to note thatcats can be
infected by hookworms. Both of these parasites have the potential to cause zoonotic disease.

Action Step: Measure the Percentage of Your Clients Who Comply with Your Recommendations for Parasite
Prevention

Make a copy of this simple tracking sheet to measure the percentage of clients who comply with your
recommendations for parasite prevention. Compare your performance with national averages.
Chapter 1 - Review: Prevalences of Canine and Feline Parasites in the United States

• As companies introduce newer, more effective products, veterinary professionals should reduce the

prevalence of parasites or eradicate them. Interestingly, if you compare surveys conducted to determine

prevalences of canine gastrointestinal parasites, you won't see a dramatic or even demonstrable decline

in prevalence rates for common canine intestinal parasites.

• The high prevalence of parasites recorded in this study indicate a need to continually monitor dogs

for parasites of zoonotic significance and, if necessary, to treat periodically to remove them.
• Looking at nationwide results for all dogs surveyed, we observed eggs of the canine hookworm,

Ancylostoma caninum, with the greatest frequency (19.19%). Researchers observed similar frequencies

nationally (14.54%) and within three of the four regions for eggs of the common roundworm, Toxocara

canis.
• As the data shows, we recovered eggs of T. canis with more frequency from dogs less than 6

months old. Although prevalences diminished as dogs aged, they were still demonstrable even in dogs

over 7 years of age.

• Despite reports of age resistance to the canine hookworm, A. caninum,44 or reduced prevalences in
 older dogs,14,15 this and other prevalence studies did not observe striking reductions in prevalences of

hookworm infections in older dogs.6,9 Infections with A. caninum occurred with similar frequencies in dogs

of all ages.
• Distinctly, intact female and male dogs were infected with T. canis and A. caninum or combinations

of these parasites with greater frequencies than either spayed female or neutered male dogs. Results of

this survey reinforce the need to monitor dogs for intestinal parasites and to treat infected animals

promptly with effective parasiticides.

• Remember that the shedding of parasites in feces can create heavily contaminated environments,

increasing the probability of reinfection of existing pets or infection of newly acquired ones.

• The feline roundworm, called Toxocara cati, is the most commonly observed internal nematode

parasite in cats in North American surveys.

Chapter 1 Pre-Test Answers:

1. The highest prevalence of intestinal nematode parasites is in the Midwest region of the United States.
False
2. Fecal flotation is not a consistently reliable method of recovering eggs of most tapeworm species. True
3. Toxocara canis, a common roundworm, is found with more frequency in dogs greater than 6 months old.
False
4. Dogs given a high level of care are known to harbor internal parasites. True
5. The feline roundworm, called Toxocara cati, is rarely observed in North American internal nematode
parasite studies. False

Chapter 2 - Understanding Your Legal Liability and Treatments for Zoonotic Diseases
Get advice on developing medical protocols, standards of care, and consent/release forms that limit your
legal liability while also giving clients the information they need to know.
By James F. Wilson DVM, JD

Test Your Current Knowledge

Is your veterinary healthcare team using consent/release forms and making sure every client
knows about the risks of zoonotic diseases? Before studying this chapter, take this pre-test to
check your awareness of veterinary legal issues regarding client education and consent.
1. The presence of single-sex parasite infections, testing during the period before roundworms
and hookworms become fully mature, or testing during a period of reduced egg shedding by
parasites can produce false-negative results. True or False?
2. Failure to diagnose and treat a pet with a zoonotic disease or to warn the owner(s) of the risks
of such diseases could pose a legal liability. True or False?
3. If clients elect not to follow your recommendations and also refuse to sign the practice's
release form, you don't need to document their decision in the medical record. True or False?
4. Even as the public's awareness of zoonotic disease rises, it is unlikely that veterinary
healthcare teams will be considered healthcare professionals, responsible for preventing such
infections because they take care of animals, not humans. True or False?
5. For a professional negligence action to be sustained, a plaintiff only needs to prove that the
veterinarian failed to follow a standard of care provided by other veterinarians in the community.
True or False?

During the last decade, the veterinary profession has seen major advances in the recognition and value of
the human-animal bond. The Argus Institute at Colorado State University in Fort Collins, Colorado, has
established criteria for bond-centered veterinary practices, and mounting volumes of research show the
value of animals in the physical, psychological, and emotional health of humans.1,2 Pets have moved from
the backyard to the bedroom and from the side yard to the sofa. Because pets may transmit serious
zoonotic diseases to humans, veterinary healthcare teams must emphasize the prevention of zoonotic
diseases with the same passion that they take toward such wellness care as vaccines and dentistry.

Growing awareness and understanding of the human-animal bond and increased use of animal-assisted
therapy have led to new perceptions of the veterinary professional's role as a public health worker. This role
is expanding and evolving to include responsibility for the health of pet owners, animal caregivers, children,
occupants of and caregivers in nursing homes and medical facilities, neighbors, family members, veterinary
teams, and the general public. Because of this increasing responsibility, legal issues and liabilities for
veterinary teams are growing.

Chapter 2 - A Growing Concern

The impact of parasitic zoonoses on the veterinary profession is significant because veterinarians diagnose
and treat family pets for these parasites. Their failure to do so may directly affect the health of humans.
Public health and potential liability issues make it essential for veterinary team members to appreciate their
vital roles in helping to minimize the transmission of zoonotic parasites to people. Today, this threat is
amplified because many veterinary professionals do not use heartworm preventives with treatment and
control of zoonotic intestinal parasites routinely, despite the increasing availability of safe and effective
broad-spectrum anthelmintics for companion animals. Veterinary professionals should review their broad-
spectrum preventive of choice to ensure treatment of common zoonotic parasites.

Physicians' awareness of the threat of zoonotic infections is belated but growing.3,4 Diagnostic testing in
human healthcare has improved remarkably while also becoming more readily available. These include
advances in the sensitivity of MRI and CT scans and their interpretations and immunologic tests for parasitic
infections. Because of these improvements, a definitive diagnosis of these infections can be made more
easily.3 In addition, growing urbanization and increased densities of human populations have enhanced the
exposure of people to companion animals and their excrement. Contaminated soil has traditionally been the
principle source of infection for humans. Children are especially at risk, because they often play in soil and
put dirt and other contaminated objects in their mouths. Other high-risk individuals include electricians,
plumbers, and workers who come in contact with soil in crawl spaces beneath buildings, as well as beach
goers whose bare skin contacts wet sand.5

Soil analyses in the United States, Great Britain, Germany, Brazil, and Czechoslovakia have shown the
presence of Toxocara eggs in 10% to 32% of soil samples taken from public places.6 Additionally, the
incidence of Ancylostoma caninum (hookworms) (Figure 1) in stray dogs has been reported to be as high as
60% to 70% in the eastern and midwestern United States. In the southeastern United States, a remarkable
86% of dogs examined at one veterinary hospital were infected with A. caninum.7 A recent study of more
than 40,000 dogs worldwide, 6,621 of which were from North America, showed a remarkable stability of T.
canis in the dog population, despite major advances in companion animal parasitic treatments and
controls.8

Figure 1 - Ancylostoma caninum (hookworm).

Chapter 2 - Which Are the Guilty Parasites?

Giardia is the most common intestinal parasite of humans, commonly causing diarrhea in humans and
animals. This disease can be transmitted to humans from other humans or from wild or domestic animals,
most commonly from contaminated water. The protozoa, called Toxoplasma gondii, also is considered a
parasite that infects humans, especially during pregnancies, in which case the parasite may be transmitted
to various organs in the developing human fetus.

The more common helminthic (parasitic worms) zoonoses include visceral and ocular larva migrans (Figure
2), due to Toxocara canis and T. cati, and cutaneous larva migrans, due to Ancylostoma braziliense, A.
caninum, Uncinaria stenocephala and Strongyloides stercoralis. Blindness is the most common result of
ocular larva migrans, while facial and other scarring occur with cutaneous larva migrans. An emerging threat
comes from the raccoon roundworm, Baylisascaris procyonis, which causes fatal or severe neurological
disease in humans. This dangerous parasite has been linked to the deaths of more than 90 species of birds
and animals, including humans.9 Increasingly common urban-based raccoons and backyard raccoon
latrines pose special risks for children.

Figure 2 - An example of ocular larva migrans.

A. caninum also has been linked to cases of enterocolitis and/or eosinophilic enteritis in humans. Affected
adults and children may develop diarrhea, abdominal cramps and pain, and eosinophilia or they may be
asymptomatic.10 Generally, these infections are not patent in humans, making diagnosis by fecal
examination unlikely.5 Occurring less frequently, but often with dire consequences, are hydatid cysts
associated with the tapeworms Echinococcus granulosus and E. multilocularis. Dipylidiasis (infection with
Dipylidium caninum), another type of tapeworm, also may cause digestive disorders, mainly in infants and
young children.11

As the number of immunosuppressed individuals in our society increases, more people may face an
increased risk for zoonotic parasitic disease. Among them are patients with Human Immunodeficiency
Disease (HIV) or the more advanced sequel to this disease, Acquired Immunodeficiency Syndrome (AIDS),
as well as those with malnutrition, diabetes mellitus, chronic kidney and liver disease, and congenital
immunodeficiences.12 Another group includes people receiving immunosuppressive therapy for cancer,
autoimmune disease, and organ or bone marrow transplants. Immunocompromised individuals are
especially susceptible to infectious organisms, including certain protozoal infections that may be transmitted
by pets, such as Toxoplasma gondii (cats), Cryptosporidium (dogs, rodents, wild birds, and pigeons), and
Giardia (dogs and cats as well as bacteria, e.g.), Bordetella bronchiseptica (dogs), and Mycobacterium
marinum (rodents, fish).10

Surveys show that of the several million immunocompromised patients in the United States, 30% to 40%
own companion animals.12 The dilemma for these patients is clear. If they keep their pets, they may run an
increased risk of infection. If they give up their pets, as physicians often advise, they may lose their best
friends and final source of comfort and companionship. One survey showed that more than 60% of pet
owners infected with the Human Immunodeficiency Virus (HIV) were advised by physicians that they should
not own pets.13 Frequently, these patients are isolated from friends and family, yet they share a close bond
with their pets to receive daily doses of love, affection, and companionship. The loss of their pets may have
devastating psychological and physical effects on these already ailing individuals.
Chapter 2 - Your Vital Role

Your role as a veterinary professional includes:

1. Passing on information you receive through your interactions with

clients to veterinarians at your practice (without invading individual rights

to privacy)

2. Assisting with the development of client-education materials, and

using them to warn clients of the risks of zoonotic disease

3. Performing accurate diagnostic tests and administering or

dispensing correct doses of medications when treating parasitic diseases

in pets

4. Educating owners about how to minimize the risk of zoonotic

diseases after they leave your veterinary practice

As a veterinary team member, you serve a critical role in counseling pet owners and helping minimize the
risks of zoonotic infection. By assisting your practice in the design and implementation of an effective
zoonotic prevention program, you can help ensure that pets are not surrendered needlessly. Your role is
especially important when pet owners are immunocompromised or severely ill. In such cases, preserving
the human-animal bond may be vital to the emotional and physical health of these pet owners.

Fecal examinations have been the traditional approach to diagnosing parasites. Historically, only pets with
confirmed parasitic infections have received anthelmintic drugs. This requirement of a definitive diagnosis of
a parasitic infection prior to the provision of medication is problematic because of the number of young
puppies and kittens that are positive and the volume of pets that may exhibit false-negative test results.
False-negatives often are found in samples that are too old, of inadequate volume, or improperly preserved.
False findings also occur because veterinary technicians and/or assistants may be inexperienced,
undertrained, careless, or don't understand the importance of their efforts performing what frequently has
been considered a mundane, smelly laboratory test. This can lead to the use of improper or inadequate
techniques to isolate and identify parasitic eggs or larvae. In addition, the presence of single-sex parasite
infections, testing during the prepatent period (before the parasites start laying eggs or passing larvae), or
testing during a period of reduced egg shedding by parasites can produce false-negative results.

What are the consequences of false-negative fecal exams? The repercussions include failure to diagnose
and treat pets for infections, increased exposure of human family and veterinary staff members, increased
contamination of neighborhood environments, damage to the pet's health from parasites, and heightened
potential for veterinary liability based on human injury. Because owners rarely have the scientific or medical
training to assess the meaning of negative fecal exams, and because attorneys may question diagnostic
protocols, contemporary veterinary teams need to adopt a different approach to managing parasitic
infections in companion animals.

Chapter 2 - New Guidelines on Preventive Deworming

The growing trend toward preventive parasite treatment began with heartworm preventive drugs. Today's
situation with companion animals should continue to move closer to that of large animal practice, where
preventive deworming has been routine for decades. Within the last 14 years, pharmaceutical companies
have added intestinal anthelmintics to heartworm medications. Combination drugs like HEARTGARD® Plus
(ivermectin/pyrantel) have paved the way for acceptance of preventive parasiticides.

Client acceptance of preventive deworming must come from the veterinarians at your practice and you.
Every staff member needs to understand the risks and help educate clients about the need and value of
such treatments. Your job must include teaching pet owners and new staff members about the incidence of
these parasitic diseases in pets, the nature of the transmission of these diseases to humans and other pets,
the risks to pets and people from such infections, and how clients may minimize their own health risks while
simultaneously helping to reduce environmental contamination.

Teach clients and staff members about:

• Zoonotic risks

• Incidence of parasitic disease in pets

• Transmission of zoonoses from animals to people

• Preventive treatments

• Environmental contamination

The educational process needs to start at staff meetings where all veterinary team members receive
information about the risks of zoonotic parasitic infections. A great way to enlighten your staff is to invite
pharmaceutical representatives to present continuing-education sessions on this topic. During training
meetings, you should evaluate the quality and quantity of existing client handouts, assess the value of
materials you may obtain from pharmaceutical companies, and determine whether you need to draft your
own. Once good client handouts are available, distributing them is an effective, though tremendously
underutilized, method of educating a naïve public. Practice-management consultants have reported that
writing a pet's name on the brochure and handing it to the pet's "mom or dad" will increase the likelihood the
client will read it by five fold. Because of the unbiased reputation of the Centers for Disease Control and
Prevention's Division of Parasitic Diseases, National Center for Infectious Diseases,5 the use of this
agency's brochure and guidelines is an excellent way to initiate the process, supplemented with vendor
handouts and, when appropriate, brochures written by your practice team. You can get the latest information
online from the CDC at www.cdc.gov/ncidod/diseases/roundwrm/roundwrm.htm.

Chapter 2 - The Issue of Liability

The legal risk for veterinary professionals is rising because of the increasing volume of research and
literature showing the connection between animal parasites and human infections. Such knowledge,
coupled with diagnostic capabilities of parasitologists, pathologists, epidemiologists, and physicians,
generates a growing legal duty for veterinary teams to foresee such risks and warn clients and family
members. Moreover, guests of those families, and/or neighbors frequenting parks, sand boxes, and yards
used by your clients' pet(s) also might contract these zoonotic parasitic diseases; thus, further extending
your liability risks. The worst case scenario: It's only a matter of time until scientists may link the DNA of the
parasite or larva infecting a human with the DNA of the parasite infesting a pet owned by an animal under
the care of a veterinarian at your practice.

As awareness of zoonotic disease rises, veterinary healthcare teams will likely be considered part of the
professionals who are responsible for preventing such infections. This is an increasing concern because of
the threat of legal liability for a veterinary practice's failure to diagnose and treat a pet with a zoonotic
disease, in addition to warning the owner(s) of the risks of such diseases.

The only legal case illustrating the magnitude of this risk occurred several years ago in New Haven,
Connecticut, where a child sustained permanent vision loss due to ocular toxocariasis.4 Medical bills
surpassed $70,000, and the pet shop that sold the puppy ultimately settled out of court for $1.5 million. The
court addressed only the issue of product liability, ruling that the pet was a product, and, as such, a strict
liability standard was enforceable. The pet shop owner decided to settle the dispute out of court. The court
never addressed the issue of negligence; although it undoubtedly would have had the case continued. The
pet shop owner allegedly was negligent for failing to deworm the puppy, failing to have any deworming
program in place, and failing to keep appropriate medical records of the pets it sold. While the defendant in
this case was a pet shop owner, veterinary professionals could easily become targets in similar cases.

Although such litigation hasn't yet implicated veterinarians, at least one suit involving zoonotic parasites has
been brought against a human medical center. The case cited medical malpractice for improper treatment of
a patient who was suspected of having toxocariasis, probably contracted from her dog.3 In addition to suing
physicians for failure to diagnose and treat parasitic diseases in humans, plaintiffs are increasingly likely to
bring actions against veterinary professionals for their negligent actions as well.

The most common avenues for plaintiff retribution include legal actions for professional negligence and
adverse public relations in the media. For a professional negligence action to be sustained, plaintiffs must
prove the existence of four elements:

1. Showing that veterinarians and their staff members had a duty to protect the injured

person.

2. Proving that the practice failed to comply with a standard of care comparable to accepted

standards for reasonably skilled and prudent veterinarians faced with similar circumstances

(with respect to the deworming of puppies and kittens, including standards created by the CDC).

3. Convincing a judge or jury that the veterinary practice's negligence was the proximate

cause of the injured person's injuries. Thus far, the near impossibility of proving this element has

been the profession's "saving grace." If DNA testing of parasitic and larval genetic materials

becomes a reality, however, it will go a long way toward overcoming this evidentiary obstacle.

4. Showing proof of damages incurred by the injured party. The diagnostic and long-term

medical care expenses alone for a human with chronic central nervous system damage could be

enormous.

Equally troubling, adverse media coverage linking a child's chronic zoonotic enterocolitis (diarrhea) to a
veterinarian's failure to diagnose and treat the child's puppy for hookworms or encephalitis from an ascarid
larva transmitted from a pet raccoon to the child's brain could be devastating to a practice and the veterinary
profession.

To avoid liability, your veterinary healthcare team should follow these steps:

1. Identify resources to educate the entire staff about zoonotic parasitic diseases. Contact

pharmaceutical representatives to serve as part of your educational team.

2. View pets as family members and acknowledge the integral role of companion animals in

family members' health status.

3. Educate clients about the health risks of parasitic infections in pets and humans.

Supplement your conversations with client handouts that provide detailed information and

document your efforts in medical records.

4. Develop preventive parasite control programs, and recommend them to all pet owners.

5. Record all medical treatments given to pets, as well as the recommended diagnostic tests
 and treatments that owners decline.

6. Make sure you and your healthcare team perform accurate fecal examinations on

appropriate samples. If you think a fecal sample submitted for your analysis is mostly mucous,

primarily grass or other foreign material, inadequate in volume, or so dried out as to be suspect,

notify the attending veterinarian of your suspicions. Make sure your training and continuing

education are adequate so you and other team members are confident with the microscopic

findings you provide. If you are not, ask another staff member or a veterinarian to help you

evaluate and correctly identify what you are seeing under the microscope.

7. As deemed appropriate by your practice manager, practice owner(s), or attending

veterinarian, ask clients to sign consent forms releasing your practice from liability if they do not

consent to recommended diagnostic procedures or deworming treatments.

In today's climate of zoonotic awareness, your veterinary team may be practicing below current medical
standards if it fails to deworm all puppies and kittens, regardless of fecal examination results. Alternatively,
team members could be contributing to the practice's liability if they have been educated but fail to
recommend and/or perform follow-up fecal exams 3 to 4 weeks after initial treatment.

Chapter 2 - Using Consent and Release Forms

A properly drafted consent/release form is a written document through which the signer agrees to waive
certain legal rights to bring a legal action for harm resulting from a designated act described in the consent.
Although consent forms are not essential in everyday practice, their use in adversarial situations with clients
is very helpful. Many times the mere request that clients read and sign such forms results in their agreement
to proceed with the recommended action.

Figure 3 - Client consent/release forms may

help protect your clinic from legal action.

The consent process serves three purposes:

1. It objectifies the request, making the veterinary professional seem less of an adversary.
 2. Many people will immediately accept your recommendation rather than sign a consent

form.

3. It educates clients and provides substantial evidence that clients were informed of the

seriousness and potential consequences of refusing treatment. Such proof constitutes a

formidable legal defense against a lawsuit for negligence.

If clients elect not to follow your recommendations and also refuse to sign a release form, you have two
options:

1. Refuse service and ask those clients to seek veterinary care elsewhere.

2. Note refusals in the patients' record and retain the client as a noncompliant client.

For more information, see the Action Step later in this chapter, which illustrates one of nearly 50 consent
forms published in the AAHA Press Legal Consent Forms for Veterinary Practices (Priority Press, Ltd, 2001)
that could be used at your veterinary practice.

Chapter 2 - Developing Preventive Deworming Protocols

To meet clients' needs, your team must become better informed about zoonotic parasitic diseases and
assist in establishing preventive deworming programs. Deworming puppies, kittens, and their mothers is one
of the most effective ways to help prevent environmental contamination and human illness, because young
animals and their mothers have the highest worm burdens and produce the most infective larvae.15,16

If you're establishing a preventive deworming program, consider this advice:

1. Set guidelines for deworming puppies and kittens. According to the CDC, puppies should receive
anthelmintic drugs at 2, 4, 6, and 8 weeks of age if both ascarids and hookworms are commonly transmitted
in your geographic area. Anthelmintic drugs may be administered at 3 weeks of age if only ascarids are
present. When treating kittens, the CDC recommends administering anthelmintics at 6, 8, and 10 weeks of
age. In all cases, nursing mothers should be treated concurrently.5 In the absence of the above deworming
program, you should deworm puppies and kittens on the first, second, and third vaccination visits,
regardless of fecal examination results.
2. Establish strategic deworming protocols for adult dogs and cats. The deworming regimen for adult
pets depends on the incidence of parasitism in your community and the degree of risk for zoonotic
transmission in the pet's environment. For dogs already receiving heartworm preventives, the use of a
product that contains ingredients against intestinal parasites is recommended. In areas endemic for zoonotic
parasites, cats and dogs belonging to non-immunocompromised owners should be dewormed at least
annually with broad-spectrum anthelmintics. Pets owned by immunocompromised clients should be
dewormed at least three times annually with broad-spectrum anthelmintics.

Deworm puppies:

• Starting at 2 weeks of age

• Repeat at 4, 6, and 8 weeks of age

Deworm kittens:
 • Starting at 6 weeks of age

• Repeat at 8 and 10 weeks of age

Chapter 2 - Conclusion

Immunocompromised pet owners and parents of young children should be especially aware of zoonotic
parasitic diseases. Veterinarians and paraprofessionals are among the healthcare practitioners who should
be informing them of these risks. Because of this, your healthcare team should implement client education
and preventive deworming protocols for companion animals. Each of you should consider yourself as a key
educator and counselor regarding the risks and benefits of pet ownership. With a comprehensive, safe, and
effective parasite prevention program, pets, owners, the public, your veterinary staff, and the veterinary
community end up winners.

Chapter 2 - Action Step: Tailor A Consent Form to Fit Your Clinic's Needs

A consent/release form helps clients understand the consequences of refusing heartworm testing and
preventives as well as fecal examinations and deworming treatments. When your veterinarians and staff
counsel clients who decline tests and treatments for zoonotic diseases, ask them to sign a form like the one
below that releases your veterinary hospital from liability:

-- EXAMPLE --

Client Refusal to Authorize and/or Pay for Recommended Canine and Feline Fecal Analyses
and/or Parasiticides
I, the undersigned owner of the pet identified below, hereby decline the fecal parasite analysis
and/or treatment for that animal recommended by ___________________ (practice name). I
understand that this fecal analysis and treatment for intestinal parasites is aimed primarily at
improving or maintaining the health of my pet. I have been informed that eliminating intestinal
parasites from my pet also is important for the health of my family and the community.

According to the Centers for Disease Control and Prevention, some dog and cat parasites may
be transmitted to humans, especially small children and immunosuppressed family members, and
may potentially cause serious health problems, ranging from skin rashes to intestinal disease,
blindness, seizures, encephalitis, and meningitis.

In the event that any individual, including myself, contracts a medical problem that could have
been diagnosed and treated by conducting this fecal analysis and/or prevented by administering
the recommended parasiticide to my pet, I agree to hold the staff of this practice harmless for any
of the fees related to the diagnosis or treatment of such symptoms, or for any temporary or
permanent injuries related to such a parasite infection that might have been prevented had such
test or treatment been performed.

_______________________________
Pet's Name
_______________________________
Owner's Signature
_______________________________
Date

Chapter 2 - Review: Understanding Your Legal Liability and Treatments for Zoonotic Diseases

• Public health and potential liability issues make it essential for veterinary team members to
appreciate their vital role in minimizing the transmission of zoonotic diseases to people. Today this threat

is amplified because some veterinary professionals don't use sufficient preventive parasite treatments,

despite the increasing availability of safe and effective broad-spectrum anthelmintics for companion

animals.
• As the number of immunosuppressed individuals increases, more people may face an increased

risk for zoonotic parasitic disease. Among them are patients with Human Immunodeficiency Syndrome

(HIV), Acquired Immunodeficiency Syndrome (AIDS), malnutrition, diabetes mellitus, chronic kidney and

liver disease, and congenital immunodeficiences.10 Another group includes people receiving

immunosuppressive therapy for cancer, autoimmune disease, and organ or bone marrow transplants.
• Your role as a veterinary professional includes: 1) identifying clients who may be at increased risk

(without invading individual rights to privacy), 2) warning all clients of the risks of zoonotic disease, 3)

performing accurate fecal analyses to identify parasitic infections, 4) administering correct dosages of

drugs to infected pets, and 5) educating owners about how to minimize the risk of zoonotic diseases.
• False-negatives often are found in samples that are too old, of inadequate volume, or improperly

preserved. False findings also occur because veterinary technicians and/or assistants may be

inexperienced, undertrained, careless or don't understand the importance of their efforts performing what

frequently has been considered a mundane, smelly laboratory test. This can lead to the use of improper

or inadequate techniques to isolate and identify parasitic eggs or larvae.

• Every veterinary staff member needs to educate clients about the need and value of such

diagnostic procedures and treatments. They must teach pet owners about the incidence of zoonotic

transmission, the risks to people from such infections, and how they can help minimize their own health

risks, and the effect such actions have in reducing environmental contamination.
• A major legal risk for veterinary practices may arise if humans contract zoonotic parasitic diseases

and the possibility exists that exposure occurred through an animal under veterinary supervision. As

awareness of zoonotic disease rises, veterinary teams will likely be considered healthcare professionals

responsible for preventing such infections.

• For a negligence action to be sustained, the plaintiff usually must show that 1) the veterinarian

failed to fulfill a duty of care to a client, 2) failed to provide a standard of care comparable to accepted

standards for reasonably skilled and prudent veterinarians faced with similar circumstances, 3) prove that

the veterinary practice's negligence was the proximate cause of the plaintiff's injuries, and 4) establish

that damages occurred as a consequence.

• In today's climate of zoonotic awareness, your veterinary team may be practicing below current

medical standards if you fail to deworm all puppies and kittens, regardless of fecal examination results.

Alternatively, as agents of the practice, team members who could be held liable for failing to assist with

recommendations for and/or perform follow-up fecal exams 3 to 4 weeks after initial treatment or who fail
 to document discussions and recommendations to clients could be contributing to the liability of attending

veterinarians and the practice.

• A consent/release form is written documentation that the signer waives certain rights to

compensation for harm resulting from a designated act described in the consent. If clients elect not to

follow the recommendations of your healthcare team and also refuse to sign the release form, you have

two options: 1) Refuse service and ask those clients to seek veterinary care elsewhere, or 2) Note

refusals in clients' records and retain them as noncompliant clients.

• For dogs already receiving heartworm preventives, a product that contains ingredients against

intestinal parasites is recommended. In areas endemic for zoonotic parasites, cats and dogs belonging to

non-immunocompromised owners should be dewormed at least annually with broad-spectrum

anthelmintics. Pets owned by immunocompromised clients should be dewormed at least three times

annually with broad-spectrum anthelmintics.

Chapter 2 Pre-Test Answers:

1. The presence of single-sex parasite infections, testing during the period before roundworms and
hookworms become fully mature, or testing during a period of reduced egg shedding by parasites can
produce false-negative results. True
2. Failure to diagnose and treat a pet with a zoonotic disease or to warn the owner(s) of the risks of such
diseases could pose a legal liability. True
3. If clients elect not to follow your recommendations and also refuse to sign the practice's release form, you
don't need to document their decision in the medical record. False
4. Even as the public's awareness of zoonotic disease rises, it is unlikely that veterinary healthcare teams
will be considered healthcare professionals, responsible for preventing such infections because they take
care of animals, not humans. False
5. For a professional negligence action to be sustained, a plaintiff only needs to prove that the veterinarian
failed to follow a standard of care provided by other veterinarians in the community. False

Chapter 3 - How to Implement a Zoonotic Educational Program at Your Veterinary Hospital

Every member of your healthcare team needs to educate clients about the importance of reducing the risk of
zoonotic diseases. Find out how you can train your staff, educate clients, and incorporate marketing
messages.
By Wendy S. Myers - President, Communication Solutions, Denver, Colorado

Test Your Current Knowledge

What are the best educational and marketing methods you can use to implement a zoonotic
educational program? Before studying this chapter, take this pre-test to check your knowledge of
effective communication techniques.
1. As a rule of thumb, the average consumer needs a minimum number of five exposures for an
advertising message to be effective. True or False?
2. A highly effective communication technique is to give the client a choice between two "yes"
options. True or False?
3. About 68% of pet owners travel with their pets, so you need to talk with clients about the
duration of preventives that treat and control intestinal parasites based on the pet's lifestyle, life
stage, overall health, and travel plans. True or False?
4. Adult pets need a fecal exam every three years to check for intestinal parasites. True or False?
5. Reading training materials generates about a 30% comprehension rate. True or False?

Mrs. Lisa Bond and her two toddlers visit your veterinary hospital with their new puppy, Maggie. The 8-week-
old Labrador retriever bounces across the floor and jumps up to kiss the children's cheeks. You can see the
special relationship this family has already established with Maggie. To help the Bond family prepare Maggie
for a lifetime of good health, you're prepared to discuss vaccinations, socialization techniques,
housebreaking, and nutrition, and answer their questions. With all the topics you need to cover, it's critical
not to forget the one subject that directly impacts the health of Maggie, Mrs. Bond, and her two toddlers:
zoonotic parasites.

Because nearly all puppies are born with Toxocara canis, the common roundworm of dogs, you need to run
a fecal test and begin a strategic deworming program immediately.1,2 Puppies may acquire T. canis from
their mothers in utero and are susceptible to infective eggs, which they begin shedding in their feces as early
as 3 weeks of age. Nursing mothers may ingest puppies' feces and the cycle of reinfestation commences.

As Mrs. Bond and her children play with Maggie, clean up after the puppy, and while working on
housebreaking, the entire family could be exposed to zoonotic parasites without precautionary
recommendations from your veterinary team. In addition to deworming for Maggie, you'll need to educate
the family about washing their hands after handling the puppy and cleaning up feces, as well as the
importance of promptly and properly disposing of feces from the backyard. A backyard contaminated with
Toxocara eggs may expose the family, neighborhood playmates, and other pets to infection. Sticky
Toxocara eggs may cling to toys, tennis balls, swing sets, and other objects that increase the potential of
infecting other animals and humans.

Educating Mrs. Bond and her family about zoonotic parasites is just one of many scenarios that you'll
encounter daily at your veterinary hospital. In addition to educating owners of puppies and kittens, you need
to inform clients with adult pets about common zoonotic parasites and share your specific recommendations
for prevention. This course summarizes research and preventive approaches to zoonotic diseases that you
and your healthcare team can use to increase your knowledge and develop educational programs for pet
owners. Let's look at the steps you need to take to create an effective zoonosis educational program for your
hospital.

Chapter 3 - Setting Your Medical Protocols

Before implementing any client-education program, your veterinarians need to agree on your clinic's
protocols for prevention and treatment. To get started, gather clinical resources from this workbook,
pharmaceutical representatives, and the Centers for Disease Control and Prevention (CDC). The CDC and
the American Association of Veterinary Parasitologists developed guidelines called "Guidelines for
Veterinarians: Prevention of Zoonotic Transmission of Ascarids and Hookworms of Dogs and Cats" To get
the latest information, visit the CDC's website at www.cdc.gov/ncidod/dpd/parasites/ascaris/prevention.htm.
You'll find guidelines on deworming young and adult pets, preventive treatments, information for
immunocompromised pet owners, and much more. The CDC also offers "Preventing Infections from Pets: A
Guide for People with HIV Infection" online at www.cdc.gov/hiv/pubs/brochure/oi_pets.htm, or call (800) 458-
5231 to order brochures.

Once you've gathered a variety of resources, veterinarians should schedule a doctors' meeting to create
written medical protocols for your hospital. Doctors need to develop protocols tailored to your clinic in three
areas:

1. How often you recommend deworming of young and adult pets

2. How often you recommend routine diagnostic tests, such as fecal and heartworm tests

3. The number of months (up to a full year) you recommend heartworm prevention and

treatment of intestinal parasites

Veterinarians will design medical protocols based on prevalence of these parasites in your community, but
they also should consider additional protocols for clients who travel with their pets. According to the
American Animal Hospital Association 2001 Pet Owner Survey, 68% of pet owners travel with their pets.
Family vacations, weekend getaways, and holiday trips to warmer climates where pets may be exposed to
zoonotic parasites pose risks, and pets may need monthly treatment for longer durations than your climate
requires.

Once doctors at your hospital create written medical protocols for the prevention and treatment of zoonotic
diseases, discuss them at a staff meeting so everyone understands how your clinic can assist in helping to
prevent zoonotic diseases. Also invite a pharmaceutical representative to your staff meeting to share the
latest research, product information, and findings on prevalences in your community. Pharmaceutical
representatives visit hundreds of clinics in their territories and can share practical tips on client education
and marketing promotions.

After discussing your clinic's medical protocols during a staff meeting, ask for volunteers from each area of
the hospital who will serve on a team that will implement your client-education and marketing programs
(Figure 1). For the best results, your team should include a veterinarian, technician and/or veterinary
assistant, practice manager, receptionist, and boarding staff member. This comprehensive representation
ensures that everyone will address how his or her respective departments will support the hospital's
zoonosis educational program.

Figure 1 - Try to include as many staff members as possible

for your clinic's zoonosis education team.

Chapter 3 - Designing Your Client-Education Program

After setting medical protocols and establishing an implementation team, you can begin to assemble the
resources and educational tools you need to educate clients. When designing your educational program,
remember to incorporate multiple learning approaches because different people learn in different ways.
Some clients may respond to written handouts while others react to visual examples. You'll want to feature a
variety of communication tools to get your message across.

Client-education teams should include:

• Veterinarian

• Technician and/or veterinary assistant

• Practice manager

• Receptionist

• Boarding staff member

Comprehension of preventing and treating zoonotic parasites increases as you elevate the level of
communication and client participation. How many exposures does a client need before the message sinks
in? The advertising industry uses rules of thumb to determine exposure effectiveness, including the three-
exposure hypothesis that addresses the minimum number of exposures needed for an advertising message
to be effective.4 The first exposure initiates a "What is it?" response. The second triggers a "What should I
do with this information?" response, and the third exposure and those thereafter remind the consumer what
he or she has learned from the first two exposures.

Studies reveal that comprehension rates increase with various communication methods:3

• Reading training material generates about a 10% comprehension rate.

• Hearing yields a 20% comprehension rate.

• Seeing increases comprehension to 30%.

• Watching someone perform the task raises comprehension to 50%.

• Participating in the task boosts comprehension to 70%.

• Doing the actual task or performing simulation alone results in a 90% comprehension rate.

An example:

• Reading a clinic handout or brochure

• Hearing you describe zoonotic parasites and explaining preventive treatments

• Seeing models or photographs of intestinal parasites

• Watching you give the first dose of a heartworm preventive or dewormer

• Participating in the care of the pet by having the client bring a fecal sample for examination and

committing to the prevention and treatment of zoonotic parasites

• Doing the task by having the client give the pet the first dose of medication in the exam room

To apply the three-exposure hypothesis in your communication with clients, let's walk through a typical
wellness visit and identify each exposure that this client has to zoonotic diseases:

Receptionist: "Good morning, Mrs. Myers and Sandy. You're here to see Dr. Good for Sandy's annual
checkup and vaccinations. Does Sandy need any heartworm preventives today? We recommend
HEARTGARD® Plus(ivermectin/pyrantel), which prevents heartworms and treats and controls five intestinal
parasites. It's also the easiest medication to administer because dogs love the real-beef Chewable and it
comes in a convenient 12-dose pack for year-round protection. Would you prefer to take Sandy's medication
now or when you checkout at the end of your visit?"

In this scenario, the receptionist greeted the client and pet by name, confirmed the reason for today's visit,
and recommended a specific product. The receptionist also used a highly effective communication
technique: giving the client a choice between two "yes" options. Next, let's see how a technician or
veterinary assistant can inform this client in the exam room.

Technician: "Good morning, Mrs. Myers and Sandy. My name is Jennifer Moore, and I'm a certified
veterinary technician who will assist Dr. Good today. She will perform a comprehensive physical
examination and give Sandy appropriate vaccinations based on her needs.I'll also get Sandy's temperature
and weight and ask you some important questions about Sandy's health and behavior. First, let me ask you
if Sandy takes monthly heartworm preventives."

Client: "Yes, she does. I give Sandy her heartworm medication on the first day of each month. She even
does tricks for it!"
Technician: "Good girl, Sandy. Besides protecting Sandy from heartworm disease, you're treating intestinal
parasites such as roundworms and hookworms. Did you know that pets can transmit these infections to
people?"

Client: "No, I had no idea. How does it happen?"

Technician: "Dogs and cats shed eggs in their feces, contaminating the environment. Hookworm larvae
may remain in the environment for months and roundworm eggs may last for years. Adult dogs like Sandy
can become infected from contaminated soil or sand, other infected pets, or crawling under porches or
raised buildings where the soil is contaminated.

"People may become infected from an environment contaminated with roundworm eggs, and hookworms
can penetrate your skin. People may experience partial or complete blindness if roundworms enter the eyes,
and hookworms may cause a skin condition called 'creeping eruption.' But the good news is that it's easy to
treat Sandy and to teach your family about preventive steps. Here is a handout that outlines our doctors'
recommendations. Let me review several key points and highlight information that you'll want to discuss with
other family members at home. Dr. Good also will recommend a fecal test today so we can check for
intestinal parasites. Because you're already giving Sandy a heartworm preventive that also includes
medication for zoonotic intestinal parasites, you're taking an important step to help protect Sandy and
reduce your family's risk of acquiring zoonotic parasites."

This technician followed the 3 C's of communication: Clear, Concise, and Caring. The message was clear
and avoided medical jargon or "veterinarianese" that might intimidate or frighten the client. The message
was concise, giving the client just the right amount of information. Providing a handout gave the client
additional information with more details, which she can share with family members at home. Lastly, the
message was caring because the technician reassured the client that she was taking proper steps to help
protect the pet and family members. Let's continue the appointment and see the veterinarian's interaction
after he performs the physical exam.

The Three C's of communication:

• Clear

• Concise

• Caring

Veterinarian: "Mrs. Myers, Sandy appears to be in good health. We've reviewed the findings of her physical
exam, fecal test, heartworm test, and blood work, and you can take home Sandy's report card so other
family members can see how well she's doing. You should continue giving Sandy a monthly heartworm
preventive so she'll be protected from heartworms and treated for intestinal parasites. We recommend an
annual fecal exam for adult dogs and monthly preventive medication. We will mail you a reminder postcard
in 12 months so you can bring in Sandy's fecal sample and get a refill of your HEARTGARD® Plus
prescription. Do you have any questions about the medication, handout, or information we discussed
today?"

This veterinarian emphasized the importance of diagnostic tests such as a heartworm test, fecal test, and
blood work. She explained steps for preventive care, including a monthly heartworm preventive that also
treats intestinal parasites and the need for routine diagnostic tests. She provided a report card and handout
so other family members not present could be equally informed. Finally, she ended the visit by asking if the
client had questions about the information discussed. Let's see how this visit ends at the front desk.

Technician: "Here is the heartworm medication that Dr. Good prescribed for Sandy. Inside, you'll find
convenient stickers you can place on your calendar to remind you when it's time to give Sandy her monthly
dose. You also can go to www.heartgard.com and register to receive a free monthly e-mail reminder when
it's time to give Sandy her chewable preventive. Here is my business card in case you or other family
members have questions about what we discussed today. Please let us know if there's anything else we can
do."

After the receptionist gives the client her invoice, she should input a reminder in the computer for the next
physical exam, fecal and heartworm tests, and heartworm preventive refill. Doing it now increases client
compliance and the quality of preventive care that each patient receives. Your veterinary team can follow the
3 R's: Recalls, Rechecks, and Reminders to help you be patient advocates and capture lost practice
revenue.

The Three R's:

• Recalls

• Rechecks

• Reminders

Chapter 3 - Developing Marketing Tools

You can enhance client education with a variety of marketing tools. Once your team has fine-tuned its
zoonosis educational messages for clients, consider ways you can incorporate it into daily practice. Here is
a checklist of promotional opportunities that can increase your effectiveness as patient advocates and
compassionate communicators:

1. Create brochure displays. Vendors can provide educational literature or you can design customized
handouts on your hospital stationery. Neatly display educational materials in wall-mounted literature racks or
countertop brochure holders (Figure 2). Place information in areas where clients can read while they wait,
such as reception areas and exam rooms. If handouts are within arm's reach, your staff and clients will be
more likely to use them frequently.

Figure 2 - Contact your pharmaceutical representative to

obtain educational brochures for your clients.

2. Design a bulletin board. You can buy cork or Post-It® Note bulletin boards from office supply stores and
hang them in each exam room and/or your reception area. Display color photos of parasites, posters, and
your clinic's preventive guidelines (Figure 3). You also might consider a map of your area that highlights
prevalences of zoonotic diseases.
 Figure 3 - Bulletin boards can be effective communication tools.

3. Publish articles in your newsletter. If your hospital sends clients a quarterly newsletter, be sure to
include a story on zoonotic diseases. Feature tips on preventing intestinal parasites, Giardia, how to clean
up after your pet, vaccinations, and more. Include pictures whenever possible because visual images along
with written advice will increase clients' understanding of the topic.

4. Insert information in new client, puppy, and kitten kits (Figure 4). If a new client recently moved to the
area, they may not know about the prevalence of zoonotic parasites in your community or ways to help
prevent problems. Likewise, owners of puppies and kittens need specific recommendations on deworming
and preventive medication. Place your handout on zoonotic diseases inside each of these kits and mark key
points with a yellow highlighter.

Figure 4 - Discuss zoonotic parasites with new puppy owners and new clients.

5. Add an announcement to your message on-hold recording. If callers listen to messages about your
clinic while on hold, add a brief statement about your clinic's recommendations for parasite treatment and
prevention. You want every client to see your hospital as the primary resource for pet healthcare
information. The subtle message may prompt callers to inquire about fecal tests, preventive medication, or
changes they've noticed in family pets.

6. Print messages on the bottom of invoices. Most veterinary software lets you put a customized
message on the bottom of statements. You also can list reminders for the next wellness exam, fecal test,
and veterinary services. Messages should be 1-2 sentences so you can quickly capture clients' attention.
Because clients visit for boarding, grooming, and pet food purchases, they may not see a veterinarian or
technician during every visit. Educational messages on the bottom of invoices subtly inform clients about
preventive care. Consider these educational messages for your invoices:

• Ask us how we can help protect your pet from intestinal parasites.

• It's heartworm season! Our clinic offers HEARTGARD® Plus, which treats and controls five

intestinal parasites.
• Do you travel with your pet? Ask us how we can help protect your pet from heartworms and treat

for intestinal parasites.

7. Review your reminder system. If your veterinary software automatically enters future reminders for
wellness exams, make sure it also inputs future reminders for fecal and heartworm tests according to your
clinic's protocols for young and adult pets. For optimal wellness, adult pets need an annual fecal exam to
check for intestinal parasites. Without reminders for fecal exams, you could miss significant practice revenue
and, more importantly, pets and family members could be exposed unnecessarily to zoonotic parasites. You
can increase the effectiveness of your reminders with a three-step process:

• First reminder: Postcard with an educational message. Industry averages show that 60% of clients

respond to a reminder postcard from their veterinarian. Click here to view a sample reminder
• Second reminder: Postcard with an urgent message that the pet may be at risk for intestinal

parasites and heartworm infection.

• Third reminder: A phone call from a staff member. This phone call can help you update practice

records and be a patient advocate. Your call can determine whether the pet is receiving veterinary

services or preventive medication elsewhere, the family has moved, or the pet is deceased. Industry

averages indicate that 70% of clients respond to a phone call from a veterinary staff member.

Ask pharmaceutical representatives about the availability of free reminder postcards. You also can use your
veterinary software to run reports on the number of canine and feline patients who are missing fecal exams
and heartworm preventives. Consider a special mailing to these clients so they can protect their family pets.

8. Use point-of-purchase displays. Advertising research shows that point-of-purchase displays play a
major role in influencing unplanned purchases and increasing sales.5 Many manufacturers will provide
attractive point-of-purchase displays that you can place near reception counters or in exam rooms. Also
display preventive medications on wall-mounted shelves or in glass cabinets with doors. You'll increase
clients' exposure to these wellness products. Reception counters often make the best placement for point-
of-purchase displays because you'll catch clients with their checkbooks out.

9. Post information on your clinic website. Feature educational articles, images of parasites, and steps
for prevention. Consider links to other educational sites, veterinary colleges, and manufacturers. If you also
distribute an e-mail newsletter, include information about zoonotic parasites and how your clinic helps
protect pets with routine screenings and monthly medication.

10. Send a news release to local media. Take a proactive public relations approach and write a news
release that discusses how your clinic helps protect pets and people from zoonotic parasites. Include a
bulleted list of guidelines from your doctors and reference information from the CDC. You can position your
clinic as a community resource for pet healthcare information. Adapt the sample news release in the "Action
Step" at the end of this chapter for your clinic.

11. Review your boarding policy. Based on doctors' recommendations, animal caretakers in your boarding
facility should update boarding forms to include your clinic's requirement for boarding-only pets that are
parasite-free and taking preventive medication. You also can add a checklist of routine veterinary services,
such as a fecal or heartworm test, that clients may request while their dog or cat is boarding at your hospital.

Lastly, keep ideas flowing. Your veterinary team should strive to constantly improve the ways you educate
clients and market preventive services. Set aside time to discuss which programs had the best results,
review monthly sales reports for preventive medication, read the latest research in veterinary journals,
attend continuing-education meetings, use role-playing to rehearse client communications, and continuously
improve your exchange of information. Your team can become more effective communicators when you
develop a comprehensive plan that involves everyone. Remember the power of TEAM: Together Everyone
Achieves More!

Chapter 3 - Action Step: Customize A News Release to Send to Local Media

-- EXAMPLE --
 FOR IMMEDIATE RELEASE:
(insert date)

CONTACTS:
(insert name/names and phone number of a doctor and/or practice manager)

Are You Reducing Your Pets' and Family's Exposure to Zoonotic Parasites?
ABC Animal Hospital offers guidelines on tests, medication,
and preventive steps that every pet owner needs to know.

CITY, STATE-As warmer weather arrives, pets need protection against heartworms and
treatment of intestinal parasites. Veterinarians and healthcare professionals at ABC Animal
Hospital, 1234 N. Main St. in Any Town, are educating pet owners about important diagnostic
tests, preventive medication, and how to help prevent the transmission of intestinal roundworms
from pets to people.

"Because our veterinarians help protect the health of pets, we discuss common zoonotic
diseases with our clients," says Dr. (insert name) of ABC Animal Hospital. "We follow guidelines
from the Centers for Disease Control and Prevention and also developed medical protocols for
our clinic based on our community."

Parasites of pets and wildlife can cause zoonotic infection when people come into contact with
the parasites' infective stages. People can be infected by ingesting infective eggs or through skin
penetration by infective larvae. Common parasites include hookworms and roundworms. ABC
Animal Hospital offers this advice to help protect pets as well as reduce families' risk of exposure
to zoonotic parasites:

• Take your pets to the veterinarian for regular visits that include a comprehensive

physical exam, fecal test to check for intestinal parasites, and preventive medication such as

HEARTGARD® Plus, which prevents heartworm disease and treats and controls five intestinal

parasites.
• Follow your veterinarian's recommendations for routine deworming of pets.

• Always clean up after your pet because eggs are shed in feces and can contaminate

backyards, parks, playgrounds, and public places.

• Cover sandboxes when not in use.

• Wash hands after handling animals or having contact with their feces.

• Make sure puppies, kittens, and new pets see a veterinarian as soon as they're adopted

so your veterinarian can begin tests and treatments for intestinal parasites.

About ABC Animal Hospital

ABC Animal Hospital is a full-service veterinary hospital that provides comprehensive medical
care and surgery for companion animals. Veterinarians take a preventive approach to wellness,
including recommending routine testing and medication to ensure pets' optimal health. ABC
Animal Hospital is open Monday to Friday from (insert hours) and Saturdays (insert hours). For
more information on zoonotic diseases or pet healthcare, call ABC Animal Hospital at (000) 555-
1212 or visit www.abcanimalhospital.com.

Chapter 3 - Review: How to Implement a Zoonotic Educational Program at Your Veterinary Hospital
• Before implementing any client education program, your veterinarians need to agree on your

clinic's protocols for prevention and treatment. To get started, gather clinical resources from this study

guide, pharmaceutical representatives, and the Centers for Disease Control and Prevention (CDC).
• Doctors need to develop protocols tailored to your clinic in three areas: 1. How often you

recommend deworming of young and adult pets; 2. How often you recommend routine diagnostic tests,

such as fecal and heartworm tests; and 3. The number of months (up to a full year) you recommend

heartworm prevention and treatment of intestinal parasites.

• According to the American Animal Hospital Association 2001 Pet Owner Survey, 68% of pet

owners travel with their pets. Family vacations, weekend getaways, and holiday travels to warmer

climates where pets could be exposed to zoonotic parasites pose risks, and pets will need monthly

medication.
• Once doctors at your hospital create written medical protocols for the prevention and treatment of

zoonotic diseases, discuss them at a staff meeting so everyone understands how your clinic can assist in

the prevention of zoonotic parasites. Also invite a pharmaceutical representative to your staff meeting to

share the latest research, product information, and findings on prevalence in your community.
• When designing your educational program, remember to incorporate multiple learning approaches

because different people learn in different ways. Some clients may respond to written handouts while

others react to visual examples.

• The advertising industry uses rules of thumb to determine exposure effectiveness, including the

three-exposure hypothesis that addresses the minimum number of exposures needed for an advertising

message to be effective.4 The first exposure initiates a "What is it?" response. The second triggers a

"What should I do with this information?" response, and the third exposure and those thereafter remind

the consumer what he or she has learned from the first two exposures.
• A highly effective communication technique is to give the client a choice between two "yes" options.

• The 3 C's of communication are: Clear, Concise, and Caring. Avoid medical jargon or

"veterinarianese" that might intimidate or frighten the client.

• Input a reminder in the computer for the next physical exam, fecal and heartworm tests, and

heartworm preventive refill. Doing it at checkout increases client compliance and the quality of preventive

care that each patient receives.

• Your veterinary team can follow the 3 R's: Recalls, Rechecks, and Reminders to help you be

patient advocates and capture lost practice revenue.

• You can enhance client education with a variety of marketing tools, including brochures, bulletin

boards, newsletters, puppy and kitten kits, new client kits, message on-hold recordings, messages on the

bottom of invoices, reminders, point-of-purchase displays, websites, and news releases.

 • Advertising research shows that point-of-purchase displays play a major role in influencing

unplanned purchases and increasing sales.5 Many manufacturers will provide attractive point-of-purchase

displays that you can place near reception checkout counters or in exam rooms.

Chapter 3 Pre-Test Answers:

1. As a rule of thumb, the average consumer needs a minimum number of five exposures for an advertising
message to be effective. False
2. A highly effective communication technique is to give the client a choice between two "yes" options. True
3. About 68% of pet owners travel with their pets, so you need to talk with clients about the duration of
preventives that treat and control intestinal parasites based on the pet's lifestyle, life stage, overall health,
and travel plans. True
4. Adult pets need a fecal exam every three years to check for intestinal parasites. False
5. Reading training materials generates about a 30% comprehension rate. False

Glossary of Terms

Zoonosis - Any disease that may be passed from animals to humans, plural - zoonoses, adjective -
zoonotic

acute - having a rapid onset and following a short but severe course

ambivalent - uncertain or unable to decide what course to follow

ancylostomiasis - infection by hookworms of the Ancylostoma species which may cause cutaneous larva
migrans (CLM) in humans

Ancylostoma braziliense - a specific type of hookworm commonly found in both dogs and cats

Ancylostoma caninum - a specific type of hookworm commonly found in dogs

anthelmintic - an agent that destroys or causes the expulsion of parasitic intestinal worms

antibodies - protein molecules produced by the immune system for defense

anticoagulant - a substance that prevents the clotting of blood

antimicrobials - a substance that kills microorganisms (such as bacteria) or suppresses their multiplication
or growth

arthropod - invertebrate having paired jointed limbs and a segmented body with an exoskeleton (i.e.,
crustaceans, arachnids, insects, myriapods)

ascarid - a type of intestinal worm that is sometimes referred to as roundworm (i.e., Toxocara canis,
Toxascaris leonina)

asymptomatic - having no symptoms of illness or disease

Bartonella - a type of gram-negative bacteria, order Rickettsiales

Baylisascaris procyonis - an ascarid (roundworm) of raccoons

blood serum - the clear liquid that separates from blood upon clotting
Bordetella bronchiseptica - gram-negative aerobic bacteria that infect the respiratory tract, resulting in a
condition commonly referred to as kennel cough

Campylobacter jejuni - gram-negative bacteria that resemble small, tightly coiled spirals; known to cause
intestinal disease

campylobacteriosis - an infection caused by the bacterium Campylobacter

cecum - the cavity in which the large intestine begins and into which the ileum opens

chronic disease - any disease that is long lasting and recurrent or characterized by long suffering

coccidia - a subclass of parasitic protozoa that is commonly found in the intestinal tract and, depending on
the species, other organs such as the liver

colonoscopy - an examination of the colon using visual tools

corneal opacity - the clouding or reduction of light passing through the clear part of the eye, the cornea

corticosteroids - a group of synthetic hormones used to suppress typical immune system response

creeping eruption - a common name for cutaneous larva migrans (CLM)

cryptosporidiosis - an infection caused by the internal parasite Cryptosporidium parvum

Cryptosporidium parvum - a small intestinal parasite which commonly causes infection in

immunocompromised persons

cutaneous larva migrans (CLM) - the human condition that results from the migration of hookworm larvae
in the skin; also called "creeping eruption"

cutaneous - of, relating to, or affecting the skin

cuticular - pertaining to the cuticle, or external protective membrane of worms

dipylidiasis - infection with Dipylidium caninum

Dipylidium caninum - a tapeworm, found in dogs and cats, whose larval stage lives in fleas

Dirofilaria immitis - a type of internal worm, commonly referred to as heartworm, that typically infects dogs
and cats; the adult stage resides in the heart and pulmonary arteries

distension - a swollen appearance that is caused by pressure from within

Echinococcus granulosus - a small tapeworm of dogs,wolves and sometimes cats

Echinococcus multicularis - a tapeworm that, in its adult form, parasitizes foxes, wild rodents and sometimes
humans

encephalitis - inflammation of the brain

endophthalmitis - inflammation involving the ocular cavities and their adjacent structures

enteritis - inflammation of the intestinal tract, especially of the small intestine

enterocolitis - an inflammation of both the small intestine and the colon

enzootic - affecting animals in a particular geographic area

enzymes - proteins that catalyze chemical reactions of other substances without being destroyed
eosinophilic - characterized by the presence of a large amount of white blood cells

fecal flotation - a laboratory method using solutions to concentrate and separate eggs of parasites from
fecal debris

flatworm - any parasitic or nonparasitic worm having a soft, flat, bilaterally symmetrical body and no body
cavity

foci - a center of interest or activity

fomite - an inanimate object or substance that is capable of transmitting infectious organisms from one
individual to another

gastrointestinal - of or relating to the stomach and intestines

geophagia - the practice of eating dirt or clay

Giardia lamblia - a specific type of protozoan parasite that inhabits the intestines of animals and people

gonadectomy - the removal of ovaries or testes; spaying; neutering

gram-negative - a quality of bacteria; gram-negative bacteria cannot be stained for inspection under a
microscope or they lose their color in alcohol

gram-positive - a quality of bacteria; gram-positive bacteria can be stained for inspection under a
microscope or they do not lose their color in alcohol

granuloma - a chronic, inflamed lesion comprised of large numbers of many different types of cells

gravid - carrying developing young or eggs

helminth - a parasitic worm

hepatic - acting on or occurring in the liver

heptomegaly - enlargement of the liver

hookworm - a type of intestinal parasitic blood-sucking worm characterized by hooked mouthparts which
are used to attach to the intestinal wall of the host

hydatid cyst - a cyst formed in the liver, or, less frequently, elsewhere, by the larval stage of Echinococcus

IgE - class of immunoglobulin associated with helminth infections

immunocompetent - having the normal bodily capacity to develop an immune response

immunocompromised - a condition in which the immune system is not functioning normally

immunodeficiency - inability to mount a normal immune response

immunoglobulin - a specific protein substance that is produced by plasma cells to aid in fighting infection

immunosuppressed - condition of having a lowered resistance to disease

lactogenic - of or pertaining to milk

laparotomy - surgical incision into the abdominal wall

larva - an immature worm that has hatched from its egg but is not yet a mature adult (pl.- larvae)

larva migrans - a human condition caused by the migration of roundworm or hookworm larvae inside the
body

laser photocoagulation - a treatment which uses a laser to destroy the larvae of parasitic worms

leukocoria - reflection from a white mass within the eye giving the appearance of a white pupil

mebendazole - an anthelmintic used to treat hookworm and roundworm infestations

microaerophilic - requiring oxygen at a level lower than that typically found in the normal sea-level
atmosphere of the earth

Microsporum - a number of fungi including the type known to cause ringworm

morbidity - sickness or disease

mucosal - pertaining to the lubricated inner lining of the mouth, nasal passages, or any lining which contains
mucous-secreting glands

Mycobacterium marinum - a specific bacterium often found in aquariums, swimming pools and diseased fish

necropsy - an examination of a dead body; autopsy

necrosis - death of cells or tissues through injury or disease, especially in a localized area of the body

nematode - any of several worms with unsegmented, cylindrical bodies, often narrowing at each end, and
including parasitic forms such as hookworms and ascarids (roundworms)

neural - of or relating to a nerve or the nervous system

neural larva migrans (NLM) - the human condition that results from the migration of ascarid (roundworm)
larvae in the body's internal organs

ocular - of, relating to, or affecting the eye

ocular larva migrans (OLM) - the condition that results from the migration of ascarid (roundworm) larvae to
the eye

opthalmoscopic - relating to examination of the interior of the eye

papillitis - inflammation of any of the projections occurring in various animal tissues and organs such as
taste buds on the tongue

papular - related to papules, small, solid elevations of the skin

parasite - an organism that grows, feeds, and is sheltered on or in a different organism while contributing
nothing to the survival of its host

parasiticide - a chemical or drug that destroys parasites

Pasteurella multodica - a specific type of rod-shaped gram-negative bacteria

patent - clearly apparent or obvious

pathogenicity - the quality of producing disease

peritonitis - an inflammation of the transparent membrane that lines the abdominal cavity in mammals and
covers most of the internal organs

pica - an abnormal craving or appetite for nonfood substances, such as dirt, paint, or clay

pneumonitis - inflammation of lung tissue

postnatal - of or occurring after birth, especially during the period immediately after birth

prenatal - existing or occurring before birth

prepatent - not yet clearly apparent or obvious; when pertaining to parasitic infection, the period elapsing
between infection and appearance of eggs or larvae from adults

prevalence - the total number of cases of a disease in a given population at a specific time

prevalent - widely or commonly occurring or existing

proclivity - a natural tendency or inclination; predisposition

prophylactic - defending or protecting from disease; preventive

protozoan - any of a large group of single-celled, usually microscopic, organisms

pruritic - severe or intense itching of the skin

pulmonary - of, relating to, or affecting the lungs

radiograph - another term for an x-ray film

rectum - The end portion of the large intestine that connects to the anus

retinochoroiditis - inflammation of the retina and middle part of the eye

ringworm - a fungal skin infection

roundworm - an unsegmented worm (sometimes referred to as an ascarid) with an elongated rounded body
pointed at both ends; usually free-living but can be parasitic

Salmonella - gram-negative bacteria known to cause intestinal disease and food poisoning

Sarcoptes scabiei - a mite that burrows into the skin and causes intense itching

serologic - relating to the science that deals with the properties and reactions of serums, especially blood
serum

seropositivity - showing positive results on serologic examination; showing a high level of antibody

seroprevalence - the rate at which a given population tests positive for particular antibodies

somatic - pertaining to the body

Staphylococcus aureus - a specific type of spherical gram-positive bacteria that tends to cause infection or
blood poisoning

Staphylococcus intermedius - a specific type of spherical gram-positive parasitic bacteria that tends to cause
infection or blood poisoning

steroids - see corticosteroids

strabismus - a visual defect in which one eye cannot focus with the other on an object because of
imbalance of the eye muscles, also called squint

streptococci - spherical gram-positive bacteria occurring in pairs or chains; commonly known to cause
tonsillitis

Strongyloides - a species of parasitic worm that commonly infects the intestines of mammals
symptomatic - exhibiting symptoms of a particular disease or infection

syndrome - a group of symptoms that collectively indicate or characterize a disease

systemic - relating to or affecting the entire body

taeniid - a family of tapeworm

tapeworms - ribbon-like flatworms that are parasitic in the intestines of humans and other vertebrates

terminal ileum - the end portion of the small intestine connected to the cecum

tinea capitis - a fungal scalp infection

tinea corporis - a fungal skin infection sometimes referred to as ringworm

titer - the concentration of a solution or amount

Toxocara canis - a specific type of ascarid (roundworm) commonly found in dogs

Toxocara cati - a specific type of ascarid (roundworm) commonly found in cats

toxocariasis - infection by roundworms of the Toxocara species which may cause visceral and ocular larva
migrans (VLM and OLM) in humans

Toxoplasma gondii - an adundant, widespread parasitic microorganism

toxoplasmosis - an acquired disease that may be characterized by fever, swollen lymph nodes, and lesions
in the liver, heart, lungs, and brain

Toxascaris leonina - a specific type of ascarid (roundworm) commonly found in both dogs and cats

tracheal - of or relating to the thin-walled tube (sometimes referred to as the windpipe) that descends from
the larynx to the bronchi and carries air to the lungs

transmammary - passing through or occurring across the mammary or milk glands

transplacental - passing through or occurring across the placenta

transverse colon - the part of the large intestine that extends across the abdominal cavity

Trichophyton - a specific type of fungus known to cause ringworm

Trichuris vulpis - a specific kind of whipworm, not known to be zoonotic

ulceration - an inflamed, often pus-producing lesion on the skin or internal mucous surface

Uncinaria stenocephala - a specific type of hookworm commonly found in both dogs and cats

visceral - pertaining to the soft internal organs of the body such as the intestines, liver, kidneys, heart and
lungs

visceral larva migrans (VLM) - the condition that results from the migration of ascarid (roundworm) larvae
into the body's internal organs

vitritis - inflammation of the clear gelatinous substance that fills the eyeball between the retina and the lens

whipworm - a slender, whip-shaped parasitic intestinal worm