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Trust, education can build vaccine compliance

As in human medicine, some veterinary clients are expressing concern over the necessity and safety of vaccines for companion animals

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Can people control their exposure to whatever virus du jour is making the rounds?

No—and that’s the point veterinarians should stress among vaccine-wary clients, says Tony Rumschlag, DVM, director of consulting veterinarians, companion animal at Elanco Animal Health.

“We cannot in all circumstances control our pets’ exposure to disease,” he says. “We can help prevent disease in our beloved pets by simply following an appropriate vaccination protocol.”

As in human medicine, some veterinary clients are expressing concern over the necessity and safety of vaccines for companion animals.

“Because some of the diseases we vaccinate against are not as prevalent as in the past, both on the human and animal side, people start to lose sight of the value of vaccines,” Dr. Rumschlag explains. “When vaccination rates decrease, these diseases tend to reappear. And I understand how pet owners can forget the extent of parvo and distemper cases we saw in the 1980s and early ’90s.”

Rumschlag says that while there is a lot of science backing the safety and value of vaccines, many of the concerns about them are based more on emotions.

“Veterinarians who have treated dogs infected with preventable diseases, such as parvo and distemper, need to share that emotional experience with clients, as the risk of infection is so much greater than the chance of a serious problem from the vaccine,” he explains.

Facts matter

How can veterinarians improve vaccine compliance among their clients? By building relationships with them and then educating them as necessary.

“We need to understand clients’ relationships with their pets and build trust based on that,” says Madeleine Stahl, DVM, associate director of scientific marketing affairs at Merck Animal Health.

“And we need to make preventive care as convenient as possible. For some clinics, having evening or weekend hours works, as do making house calls and practicing forward scheduling.”

Karen Stasiak, MSN, DVM, veterinary medical lead, biologicals at Zoetis, says that relationship must cover all medical recommendations, not just vaccines.

“Pet owners are concerned about safety, efficacy, and costs,” she says. “And sometimes veterinarians have their own barriers to overcome. They get frustrated when their recommendations aren’t followed, and that can keep them from making recommendations. That’s when your strategy needs to address science issues.”

And that means education.

“One way to educate clients is by asking the lifestyle questions through risk assessment,” Rumschlag says. “By starting with these questions, veterinarians can evaluate which diseases the pet is likely to be exposed to and then educate the client on why vaccinating against these diseases is important.

“Discussing the symptoms of these diseases and how they are transmitted, in conjunction with data on the prevalence of these diseases in their region, can help the client understand the need for appropriate vaccination,” he says, citing American Animal Hospital Association’s (AAHA’s) 2017 Canine Vaccination Guidelines.

“There are still areas of the country where mass vaccination is less common in animals, and these diseases remain a threat to pet welfare,” Rumschlag says.

An obvious educational tool that shouldn’t be overlooked, Dr. Stahl notes, is your clinic’s website.

“Most of our clients are on the go, so you need to be sure your website is mobile friendly,” she explains. “You should be providing fresh content on the site on a regular basis—it shouldn’t be an afterthought.

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“Use social media. That’s where your clients are. Make it fun; provide a lifestyle questionnaire to help clients understand which vaccines their pet needs. Recommend reputable websites on diseases, such as dogflu.com and stoplepto.com. Share videos and pet owner brochures. You can get many of these things free of charge from vaccine manufacturers.”

Reinforcing the vaccine message

Another tactic is to revisit vaccine recommendations at every office visit, Dr. Stasiak says.

“Repetition is the key, and it helps facilitate conversations,” she says. “Remember, clients can get a lot of information off the internet. Sometimes it’s good, but often it is not.”

As in pediatric medicine, one concern cited by pet owners is whether current practices constitute over-vaccination.

“Vaccines should never be given needlessly,” Rumschlag says, citing AAHA’s 2011 Canine Vaccination Guidelines. “Vaccines are biologic products and should be tailored to the individual pet. In addition, one should keep in mind the pet’s needs may change over time due to travel or other activities.”

The real concern, Stasiak says, is under-vaccinating, not over-vaccinating.

“This is really important to recognize,” she says. “Thousands of dogs have gotten canine influenza, and leptospirosis and Lyme disease are increasing. Vaccinating has become a victim of its own success. When disease lessens, the need seems to lessen, and it makes some clients question all vaccinations for animals. But there are emerging and spreading diseases for which pets need to be vaccinated.

“Core vaccines are recommended every three years, and they are important to prevent zoonotic diseases, especially when so many owners let their dogs sleep in their beds.”

Stahl notes vaccinations have increased human survival rates dramatically, and we’re seeing this in pets as well.

“But today there are more dangerous diseases that can spread from animals to people. So it’s important to have honest conversations on the lifestyle of the pet. Ultimately, we have a moral obligation to prevent diseases.”

Still, some pet owners aren’t convinced vaccines are safe.

“Because of advances in technology, they are safer today than ever before,” Stahl says. “They stimulate the animals’ natural defense system. But they are still a medical procedure, and the risk-to-benefit ratio must be weighed. In most cases, however, the benefits of vaccines outweigh potential adverse events.”

Stasiak agrees.

“I let my pet owners know that before the United States Department of Agriculture (USDA) approves vaccines, the manufacturer is required to demonstrate effectiveness. Severe reactions are rare, and tend to be more associated with older vaccines. Technology has improved so much that the risk of disease far outweighs the risk of a bad reaction.”

What are the chances?

Rumschlag says large studies measuring vaccine safety statistics estimate death in 2.4 of one million dogs and 8.1 of one million cats, citing Moore 2005 and Moore 2007.

“This is real, but massively less risky than dying from a preventable disease,” he says. “To put it in perspective, the National Weather Service shows people have a one in 14,600 chance of getting struck by lightning in their lifetimes. Is going outside safe?

“Any procedure we perform on our pets carries some degree of risk, which is why a veterinarian’s involvement in the decision is so crucial. We advocate the veterinarian perform an individual health assessment, use the latest vaccine protocols, and have a monitoring plan to mitigate the risks.”

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Pet vaccine skeptics also complain that whether you have a Chihuahua or a Great Dane, it gets the same amount of vaccine.

Rumschlag says a pet’s size isn’t relevant when it comes to vaccines.

“When we inject rabies, we introduce inactivated viruses to a very small part of the body,” he explains. “These are processed by white blood cells called antigen-presenting cells. These cells release chemicals called cytokines, which go to the local lymph node, tell that lymph node to wake up, and that lymph node starts telling other lymph nodes to wake up as well.

“To get the entire body to create a protective response, we really only need to get one lymph node properly activated and it does the rest,” Rumschlag adds.

“So we are only dosing a very small area of any dog with a rabies vaccine. The immune response in one Chihuahua lymph node is the same as the immune response in one Great Dane lymph node, even though the body sizes are dramatically different. The critical factor isn’t the size of the dog. Rather it is that one lymph node be properly activated, and that is why we use the same injection on every dog.”

Stahl agrees, adding vaccines aren’t like pharmaceuticals. “Antibiotics are dosed on body weight, but vaccines are based not on volume but an immunizing dose. For that, there’s no difference between the Chihuahua and Great Dane.”

Prepping protocols

When establishing vaccine protocols, Rumschlag reminds veterinarians to consider the types of vaccines administered, expected onset of immunity, expected duration of immunity, and proper storage and handling. The pet’s age and health also may influence vaccination protocol decisions.

“It is important to remember vaccines should be administered in a series to both puppies and kittens, ensuring an adequate immune response develops after maternal antibodies have waned,” Rumschlag says.

“It is recommended to vaccinate at an interval of three to four weeks until 16 weeks of age to achieve an optimal outcome.” He cites the American Association of Feline Practitioners’ (AAFP’s) Feline Vaccination Guidelines 2013 (page 802) and AAHA’s 2011 Canine Vaccination Guidelines (page 12).

“And remind pet owners that vaccines do not work immediately,” he adds. “Depending on the type of vaccine product used, it may take several days to several weeks for immunity to develop.”

Stahl stresses vaccines also are important for preventing disease in other pets in the community. For instances, she says, dogs carrying canine flu may not appear ill, but can still spread the disease.

“Veterinarians should discuss the potential risks with clients,” she adds. “Once a disease is in the community, it’s too late. We need a large number of vaccinated pets for community immunity.”

She notes vaccinations also play a central role in minimizing antimicrobial resistance. “When we avoid diseases by vaccinating, we reduce the need for antibiotic treatment.”

Stasiak says she has frequently heard veterinarians say they wait for clients to ask about vaccines, but says that’s a bad idea.

“They rely on you, the veterinarian, to make recommendations. We should encourage them to know the cost of vaccines is far less than the cost of treating illness. It’s up to veterinarians to recommend vaccines.”

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Finally, Rumschlag says, consider the vaccine visit and the impact it can have on the comfort of the pet and pet owner.

“Using principles and hospital approaches, such as those suggested by Fear Free, can help improve client satisfaction with the vaccine experience,” he adds.

When it comes to vaccines, there’s no such thing as an indoor-only cat

Cat owners are sometimes quick to tell their veterinarian their pet doesn’t need vaccinations “because she’s an indoor cat.”

Yet, according to companion animal vaccine specialists, that pet owner needs to be educated on the danger of not vaccinating.

“Inside cats still require vaccination against serious and deadly diseases,” says Madeleine Stahl, DVM, associate director of scientific marketing affairs at Merck Animal Health. “Feline households often have more than one animal. It’s important to uncover if there are others that go outside, even if it’s accidental.

“Canine family members can track in parasites or viruses. Even humans can bring hardy viruses in on shoes. And wildlife can make its way into homes. It’s not rare to find your cat playing with a bat in the house. Things happen, and you need to be prepared.”

Karen Stasiak, DVM, regional strategic veterinarian with Zoetis, agrees.

“I tell pet owners that all young animals need to complete the full vaccine series. After that, lifestyle can help determine needed vaccinations. Cat diseases can be carried inside, and indoor cats can get outside accidentally. Some cats hang outside on balconies with their owners, and sometimes they sit in a doorway or window with only a screen separating them from outside animals.

“And most of my cat clients think nothing of bringing home a stray cat or kitten. Vaccinating ‘indoor’ cats takes that risk away.”

Boarding pets and local rabies vaccine requirements also are reasons for full feline vaccination, says Tony Rumschlag, DVM, director of consulting veterinarians, companion animal at Elanco Animal Health.

“On some occasions, it might be necessary for an owner to board their cat, where pathogen exposure can occur,” he says. “And in most states, rabies vaccination is required by law, even for indoor cats.”

The subject of feline injection-site sarcomas—originally referred to as vaccine-associated sarcomas—still evokes strong emotions and opinions, Dr. Stasiak says.

“[It] remains muddled at best,” she says. “Answers still elude us after 20 years of research. It applies to all injections, not just vaccines, and the incidence is so rare, estimated at less than one case in 10,000. But I do worry it keeps people from vaccinating their cats.”

“What is apparent,” Dr. Rumschlag says, “is that sarcomas associated with vaccination have a wide variety of both extrinsic and intrinsic factors, and there is no consensus on the ability of vaccine type to influence the incidence of feline injection-site sarcoma.”

Vaccinations are not uniquely implicated, Dr. Stahl notes. “Even trauma can be associated with the sarcoma. Bottom line is that today, studies have found no relationship between type of vaccine and the risk of a subsequent sarcoma. It’s likely a complex interaction of extrinsic factors, injection frequency and number of injections, along with genetic predisposition. But it doesn’t compare with the risk of common feline diseases that are preventable with vaccines.”

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