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  1. Please cite this presentation as: • Speare R. The role of veterinary education on zoonotic diseases and emerging diseases. Agriculture Fisheries and Conservation Department Annual Animal Health Workshop: Veterinary Education; Hong Kong. 23-24 January, 2013.

  2. The role of veterinary education on zoonotic diseases and emerging diseases Emeritus Professor Rick Speare • Tropical Health Solutions & James Cook University Townsville 23 January 2013 rickspeare@gmail.com

  3. My perspective • Vet, doctor, public health physician • Researching control of communicable diseases in animals and humans for over 30 years • Teaching postgraduate public health (Anton Breinl Centre for Public Health & Tropical Medicine) – zoonoses and EIDs – to doctors, nurses, allied health, veterinarians – 1991-2012 • Highlighting need for human and animal health professionals to work together • Realising that the current training for both keeps them apart

  4. When is a new vet school / college needed? • Australia agonised over this question in the late 1990s • 4 veterinary schools since the 1970s • Finally decided in early 2000s to add 2 more in non-capital cities (Rural vet schools) • James Cook University (Townsville) • Charles Sturt University (Wagga Wagga)

  5. Residents per veterinary school: Australia • Population = 22,015,600 • Veterinary schools = 6 • Residents/vet school = 3,669,263 • Canada = 8,575,021 • New Zealand = 4,327,944 • UK = 9,006,737 • USA = 11,208,838

  6. Global statistics • 5.5% of world’s population do not have a veterinary college / school in their country

  7. Distribution of residents/ vet school by country China = 74,624,440 18 vet schools Statistics at www.tropicalhealthsolutions.com/veterinaryeducation Hong Kong = 7,153,519 1 vet school? India = 41,554,262 29 vet schools Australia = 3,669,263 6 vet schools Taiwan = 5,808,734 5 vet schools

  8. Proportion of countries by “continent” that have a vet school

  9. Establishing new professional degrees: Learnings from James Cook Uni (JCU) • We started 11 professional UG degrees • 1980s – Bachelor of Nursing Science • 1990s – B. Occupational Therapy; B. Speech Pathology; B. Sports & Exercise Science; B. Biomedical Science; B. Medical Laboratory Science; B. Pharmacy; B. Physiotherapy; B. Medicine B. Surgery • 2000s – B. Veterinary Science; B. Dentistry • Although meeting the original needs was important, the major benefits came from massive increases in professional capacity in the local area: • specialists, new people, new ideas, higher quality, research answering local questions, new activities

  10. Accreditation of degrees • Universities are free to establish degrees in any discipline • If a degree is recognised (accredited) by a professional body, the successful student is granted admission to that profession • If the degree is not recognised, the student may not be granted entry to the profession, or only granted entry after doing additional training, and/or sitting a professional exam • Accreditation saves effort by the student and gives status to the degree offered

  11. Are zoonotic diseases and emerging infectious diseases a criteria for accreditation of veterinary schools?Are they a core content for accreditation?Are they a “must have” rather than a “should have”?

  12. The Australian & New Zealand requirements • Accreditation is granted by the Australasian Veterinary Boards Council Inc (AVBC) • Veterinary Schools Accreditation Advisory Committee (VSAAC) deals with accreditation of veterinary schools • They use 12 standards for accreditation • Key document is the VSAAC Policies, Procedures and Standards

  13. 12 standards of AVBC • Standard 1: Organisation • Standard 2: Finances • Standard 3: Facilities and equipment • Standard 4: Library and learning resources • Standard 5: Animals and related resources • Standard 6: Admission and students • Standard 7: Curriculum • Standard 8: Clinical resources and clinical learning and teaching • Standard 9: Academic and support staff • Standard 10: Postgraduate training and continuing education • Standard 11: Research • Standard 12: Outcomes assessment

  14. Search of the VSAAC document • Searched for “zoonoses”, “emerging infectious diseases”, “biosecurity”, “one health”, “one medicine” • Hits: • “zoonoses” = 5 • “emerging infectious diseases” = 0 • “biosecurity” = 5 • “one health” = 0 • “one medicine” = 0

  15. Standard 7. Curriculum AVBC recognizes that curricula need to be flexible but the following areas must be covered: • “- Instruction in the theory and practice of medicine and surgery applicable to a broad range of species. The instruction must include principles and hands-on experiences in physical and laboratory diagnostic techniques and interpretation (including clinical pathology, diagnostic imaging and necropsy), disease prevention, biosecurity, therapy (including surgery), patient management and care (including intensive care, emergency medicine and isolation procedures) involving clinical diseases of individual animals and populations. • - Instruction in the principles of preventive medicine/epidemiology, zoonoses, food safety, the interrelationship of animals and the environment.”

  16. Standard 8: Clinical resources and clinical learning and teaching Expectations and Outcomes • “- Provides instruction on the principles and practices of biosecurity within a clinical setting, including the students’ active participation in the use of isolation facilities.”

  17. Essential Competences Required of the Veterinary Surgeon Essential Competences Required of the Veterinary Surgeon Attributes relating to knowledge and understanding “Graduates will be able to demonstrate knowledge and understanding of: • The principles of epidemiology and zoonoses of disease and their impact on the environment;” (p28) Attributes relating to attitudes as they affect professional behavior “Graduates should have developed the following skills: • Recognition of the critical role of the veterinarian in biosecurity and in the management of veterinary issues that have national and international implications.” (p28)

  18. Annex 8 VSAAC requirements for Universities Implementing a ‘Distributed’ or ‘Off-campus’ Veterinary Clinical Education Model Facilities • “15. The facilities and equipment at off-campus veterinary clinics, practices and hospitals used for distributed teaching must meet the applicable state or national standards or codes, including compliance with all relevant legislation. The requirements for such facilities is that they meet “best practice” standards for veterinary hospitals and meet relevant standards for occupational health and safety, animal welfare and biosecurity. Ongoing compliance must be regularly reviewed (at least 12 monthly) by suitably qualified university staff or others.” (p102)

  19. Accreditation requirements for other developed countries were similar • American Veterinary Medical Association • Royal College of Veterinary Surgeons

  20. Importance of the Topics • Zoonoses and biosecurity are core content required for accreditation of veterinary schools. Very important. • The newer concepts of emerging infectious diseases (EIDs) and One World / One Health are not listed as core content. • However, EIDs are rapidly increasing in importance. • One Health is arguably an approach that will lead to improved control of zoonotic diseases. Important, but not yet critically so.

  21. Important Definitions • Zoonoses • Emerging infectious diseases (EIDs) • Zoonotic EIDs • Biosecurity • One Health • Veterinary Education

  22. Zoonosis A disease or agent transmitted from non-human vertebrate animals to humans • 816 zoonotic pathogens • 1,407 human pathogens overall • Zoonoses = 58% • (Woolhouse & Gowtage-Sequeria EID 2005;11(12):1842)

  23. What animal hosts carry zoonotic pathogens? Woolhouse & Gowtage-Sequeria EID 2005;11(12):1842

  24. A scheme for classifying zoonoses • Zoonoses are complex • Most zoonoses have R0<1; so do not cause outbreaks • Can be classified in many ways • Agent, route of transmission, occupation, pathology • One approach classifies them into types by the persistence of the zoonotic pathogen in humans and the ongoing relationship with an animal source

  25. Zoonoses: type 1 • Vertebrate animal reservoir, spillover to humans; humans are a dead-end host • Animal hosts may be single species or multiple Animal Animal Human • This interaction occurs in an environment Add climate change!

  26. Example of type 1: leptospirosis • Small animal vet in Washington State (USA) examined a pet rat • Rat urinated on his hands • Washed hands routinely • Developed leptospirosis 10 days later • Diagnosis delayed until day 16 since leptospirosis was not considered Baer et al. Zoonoses and Public Health 2010;57:281

  27. Role for vets • Protect themselves – good infection control; recognise risky situations • Protect staff – as above • Protect clients – as above; advise them in prevention • Remind doctors to think of zoonoses for any febrile illness • Conduct hazard analysis - risk reduction • When reducing infection risks start with higher order controls (elimination, substitution, isolation, redesign and engineering)

  28. Higher order controls are more effective • Work health and safety approach Thanks to Tricia Coward QWHS

  29. Biosecurity • Safeguarding of resources from biological threats • Encompasses the full spectrum of biological risk whether naturally occurring harmful organisms, or introduced by accidents and/or negligence through to their deliberate use as biological weapons • Term “biosecurity” is used in many different ways and often tailored for the particular situation • Infection control is one component of biosecurity

  30. Zoonoses: type 2 • Vertebrate animal reservoir, spillover to humans; limited human to human transmission • About 25% of zoonoses Animal Animal Human Human

  31. Example of type 2:Salmonellosis • 1999; SalmonellaTyphimurium (multi-drug resistant) killed 9 cats in an animal shelter • People who adopted kittens from the shelter became infected (primary human cases) • One infected child passed their infection onto 2 children at a day care centre (secondary human cases) Wright et al EID 2005;12(8):1235 Figure 1. Date of death among cats and week of illness onset among human case-patients, Minnesota, 1999.

  32. Role for vets • Protect themselves – good infection control; recognise risky situations • Protect staff – as above • Protect clients – as above; advise them in prevention • Remind doctors to think of zoonoses for any febrile illness • Assist/initiate epidemiological investigations • Conduct hazard analysis - risk reduction • If higher order strategies (elimination, substitution, isolation) are an option, initiate these

  33. Zoonoses: type 3 • Vertebrate animal reservoir, spillover to humans; well adapted human to human transmission; spillback to animals Animal Animal Human Human Two way transmission = anthropozoonosis Human to vertebrate animal transmission = humanosis

  34. Example of type 3:Influenza A • Influenza A infects humans, birds, pigs and variably other mammals • Strains tend to associate with host groups, but can spillover to other hosts • If dual infection occurs in an individual host, RNA strands can mix (reassort), and a new strain can be excreted • For humans if i) the new strain transmits readily person to person, ii) the antigens are novel (no widespread immunity) and iii) the virus is pathogenic, a pandemic can occur • In 2009 a new strain of Influenza A H1N1 with genes from human, bird and pig influenzas caused a pandemic

  35. Reassortment Mixing vessel host • During this pandemic there were several instances of humans transmitting H1N1p2009 to pigs and poultry • Viral genetics showed that human to pig transmission was frequent during and after the pandemic (Nelson et al. J Gen Vir 2012;93:2195)

  36. Role for vets • Protect themselves, staff & clients – infection control against droplet infection • Encourage influenza vaccination of staff and clients to decrease risk of reassortment • Advise clients to protect their pigs and poultry against risk of transmission from wild birds and human workers • Assist with surveillance in animals • Assist in outbreak investigation and control

  37. How to tell if an arriving flight has bird flu…

  38. Escaped Zoonoses! • Many human diseases started as zoonoses, adapted 100% to humans, and animals are no longer needed (eg, measles) • Most recent example is HIV Animal Animal Human Human

  39. Human Immunodeficiency Viruses Example of a group of viruses that made a cross-species transmission (zoonosis) and Then became a “natural” human pathogen

  40. Simian Immunodeficiency Viruses: Origin of HIV Wertheim & Worobey (2009)

  41. Simian Immunodeficiency Viruses: Origin of HIV • HIV-1 = from SIVcpz from chimpanzee (Central Africa: Cameroon) • HIV-2 = from SIVsm from sooty mangabey (West Africa: Côte d'Ivoire) • 11 instances of non-human primate to human transmission of SIV to HIV

  42. Non-Human Primate to Human Transmission Outcomes • SIVcpzHIV-1 gp M • SIVcpzHIV-1 gp N • SIVcpzHIV 1 gp O • SIVsm HIV-2 gp A • SIVsm HIV-2 gp B • SIVsm HIV-2 gp C • SIVsm HIV-2 gp D • SIVsm HIV-2 gp E • SIVsm HIV-2 gp F • SIVsm HIV-2 gp G • SIVsm HIV-2 gp H Wertheim & Worobey (2009)

  43. Non-Human Primate to Human Transmission Outcomes • SIVcpz HIV-1 gp M  Human to human transmission • SIVcpz HIV-1 gp N  Human to human transmission • SIVcpz HIV 1 GP O  Human to human transmission • SIVsm HIV-2 gp A  Human to human transmission • SIVsm HIV-2 gp B  Human to human transmission • SIVsm HIV-2 gp C • SIVsm HIV-2 gp D • SIVsm HIV-2 gp E • SIVsm HIV-2 gp F • SIVsm HIV-2 gp G • SIVsm HIV-2 gp H Group M then caused pandemic AIDS

  44. Oldest date for the cross-species jump? • HIV-1 gp M – 1900s • HIV-1 gp N - 1963 • HIV-1 gp O – 1920 • HIV-2 A – 1932 • HIV-2 B - 1935 Wertheim & Worobey (2009)

  45. Why did HIV become a pandemic? • All about probabilities • Spillovers = many opportunities • Bushmeat hypothesis • Going global • Urbanisation hypothesis • Unsafe sex more frequent • Rapid transport of infected people long distances A butchered monkey at a market in the Congo has been partially cooked. Nat. Geographic

  46. Any role for vets in HIV/AIDS? • Physicians do not talk to HIV/AIDS patients about zoonotic diseases (7% in USA Hill et al 2012) • Vets do talk to HIV/AIDS clients about zoonoses (69% in USA) • Physicians should refer patients to vets for advice ….. But they don’t! • Vets and physicians don’t talk to one another • Vets have an important role in informing HIV/AIDS patients and doctors about zoonotic risks • But their knowledge about specific risks for HIV/AIDS patients is low (in USA) Hill et al. JAVMA 2012; 240(12):1432

  47. Zoonoses: type 4 • Vertebrate animal reservoir; human reservoir; pathogen strains adapted to both; two way transmission Animal Animal Human Human

  48. Example of type 4:Methicillin resistant Staphylococcus aureus MRSA: a humanosis becomes a zoonosis ICU Hospital Community acquired MRSA

  49. Human cases: Is there an animal MRSA source? • Recurrent clinical episodes in a patient • Pet or livestock contact? • Recurrent MRSA carriage in health care staff • Live on a farm? • Pets? J Hosp Inf 2008;700186

  50. MRSA: an occupational zoonosis for veterinarians • Vets have an increased prevalence of community acquired-MRSA carriage • Shown in several developed countries • Australian vets: • Industry & Govt vets (desk jockeys) 0.9% • Equine-only vets 21% • Vets who treat horses 12% • Small animal vets 4.9% Jordan et al. Aust Vet J 2011;89(5):152 Carriage of MRSA increases likelihood of invasive disease