RISING TO THE OCCASION

The novel coronavirus caught many off guard, but in some ways, veterinarians were better prepared for the pandemic than most. Veterinarians keenly understand how viruses infect hosts and can mutate over time. So Dr. Rob Conner, a practice owner in rural northern Arkansas, took matters into his own hands by securing personal protective equipment in a creative manner (see page 555). He remains convinced that veterinarians should have been put in charge of the response to the coronavirus given the U.S. Department of Agriculture's efforts with animal disease traceability.

“It's a little befuddling to me to watch our government not know what to do or corral it (COVID-19),” Dr. Conner said. “It is a very complex thing. Fortunately, kind of like any problem, you study it, dissect it, learn details about it, and figure out how to battle it.”

Indeed, veterinarians have been involved in cutting-edge research on SARS-CoV-2, not only helping develop potential vaccines, but also studying how the virus affects humans and animals (see page 563). Veterinarians in the clinic quickly figured out how to continue to meet the needs of their patients while keeping everyone safe.

Equine veterinarians have had to limit how many people attend an appointment and more rigorously disinfect their vehicles and equipment, among other protocols. Zoo veterinarians, too, had to take extra precautions, particularly for certain species in their care after lions, tigers, snow leopards, and gorillas have caught the virus from asymptomatic staff members.

Swine veterinarians encountered a uniquely difficult situation early in the pandemic when processing plant workers' exposure to COVID-19 led to a backlog of market swine. At its lowest, daily processing capacity dropped to approximately 42% during April 2020, which meant approximately 215,000 hogs per day were not able to be harvested at that time, according to Dr. Harry Snelson, executive director of the American Association of Swine Veterinarians, in the September and October 2020 issue of the AASV's Journal of Swine Health and Production.

Farmers and swine veterinarians responded by attempting to hold animals in place, slow growth, repurpose vacant facilities, adopt nontraditional marketing strategies, and alter breeding programs to enable producers to avoid or delay much of the anticipated depopulation.

Ultimately, however, depopulation was unavoidable for thousands of animals.

BUSY, BUSY, BUSY

And throughout this time, the AVMA and others have worked relentlessly to keep veterinarians apprised of the latest information and what it means, from whether SARS-CoV-2 can be transmitted to animals or vice versa to how practice owners could apply for Paycheck Protection Program loans. The AVMA has produced dozens of tools, guidance documents, and webinars to help practitioners navigate telehealth, manage exposed staff members, and more. These resources, available at avma.org/coronavirus help veterinarians provide care for pets, horses, and livestock, including safeguarding the nation's food supply; laboratory animals; and aquatic, exotic, and wild animals. Cumulatively, AVMA webpages dedicated to COVID-19 had received nearly 2 million page views as of Jan. 31. And the AVMA has tracked 7,672 mentions of the AVMA in coverage of COVID-19 by the media as of Jan. 31, with a total reach of 16.46 billion impressions.

So here we are, a year later. Veterinarians remain as resilient as ever, even through these difficult times. On the one hand, many practices are doing better than ever (see page 567), and the number of pets continues to increase. On the other hand, clinics have gotten so busy they're doing what was once unthinkable to many—turning clients away.

Dr. Michael Longoni is medical director of Diamond Veterinary Hospital, a 24-hour emergency and general practice in Everett, Washington, where the first cases of COVID-19 in the U.S. were documented. He said business slowed for two weeks when the pandemic first hit. Since then, he said, “We got even busier because a lot of practices that could have theoretically stayed open, a fair amount just closed. Their clients ended up coming to us for emergency care and chronic illness things. Our ER (emergency room) got busier and stayed growing and getting busier through the whole thing (pandemic), to the point where there are two other ERs close by, and they are swamped, too. It's gotten to the point where we've added a midshift ER doctor and started calling capacity,” not seeing more emergency cases until the staff catches up, except for certain critical cases. “We had never done that before, but we had to just for our employees' sake. We have to have a relief valve. It's hard because we're turning people away, which makes our receptionists' job harder.”

He says some clinics still can't get clients in for an appointment for three to four weeks.

“When we see an emergency, we tell them to go back to your vet for a follow-up, but they can't get in any sooner than they can for a recheck here. We've built some leeway in our schedule to anticipate that,” he said. “It's kind of a concentrated problem in the ERs, not able to help as many animals as they want.”

SELF-CARE AND COMMUNICATION

Burnout, compassion fatigue, and suicidal ideation are as much, if not more so, issues for practitioners during the pandemic.

Melissa Mace, executive director of the Wisconsin Veterinary Medical Examiners Board, said it was somewhat lucky that the board established a Veterinary Professional Assistance Program in November 2020 as the program has provided important resources during this stressful time. The board started working on the program more than two years ago. Similar to programs in other states, the VPAP offers guidance and assistance with family issues, finding child and adult care, workplace concerns, legal and financial issues, stress, health and wellness, and other issues that concern veterinary professionals. It also offers personal, confidential guidance, coaching, and counseling for all veterinary professionals and their household members. The VPAP has resources geared toward helping veterinary professionals navigate the COVID-19 environment, too.

“They (veterinarians) are a unique group of people who have a unique group of stressors, which can be more exacerbated in some areas. We wanted to give them support across the board,” Mace said. “If they're in crisis, they can pick up the phone and call and have no ramifications against their credential.”

Since COVID-19 has hit, Mace said, the board has seen an increase in complaints having to do with veterinarian-client communication.

“Good communication in a stressful situation is always challenging. COVID is a good example of difficult communication in the clinic setting. Clients are sitting in the car. Their pet is in the clinic with staff, who are calling them to discuss diagnosis and treatment options. The conversation isn't the same as it would be in person, and at times the consent is not quite as clear,” Mace said. “If a client is stressed and doesn't understand what they're being told, clinic staff can't see them to read the body language that may help them figure out their message is not being received, and if there's a bad outcome, that leads to a complaint and hard feelings.”

Despite the challenges, curbside pickup and dropoff along with telehealth have allowed veterinarians to maintain services and interact with clients quickly and efficiently while also reducing their risk of exposure to the virus.

But not all have not gone untouched, as colleagues have fallen ill or died of the virus. Although considered health care workers and owners of essential businesses, not all veterinarians were at the front of the line for vaccines when they became available (see page 561).

In this issue, JAVMA News seeks to tell stories of the hard work of clinicians and researchers, clinic staff members, and students who have had to navigate uncharted waters during what was already a time of stress and uncertainty. Their dedication to the veterinary profession has helped ensure the health and safety of animals and people alike.

STUDENT CONFIDENCE

Dr. Nicholas Frank, associate dean for academic affairs at the Cummings School of Veterinary Medicine at Tufts University, said many veterinary students are nervous about graduation.

“Even under normal circumstances, many students feel worried about their abilities as they near the end of their training and start looking for jobs,” he said. “The overall stress of the pandemic is likely to be making this worse, and it is understandable that you have concerns.”

Dr. Frank, 2021–22 chair of the AAVMC Academic Affairs Committee, said many employers expect to provide new graduates with further guidance. He said to focus on asking for feedback and requesting assistance as key strategies for success in any environment.

“You have seen the importance of practicing team-based veterinary medicine during the pandemic and the benefits of having a strong community, so keep these in mind as you take the next step,” he tells fourth-year students.

Dr. Jared Danielson, associate dean of academic and student affairs at Iowa State University College of Veterinary Medicine, said students are still learning the skills they need.

“We have a set of graduation requirements that are based on accreditation and clinical skills they have to prove they can do,” said Dr. Danielson, 2019–20 chair of the AAVMC Academic Affairs Committee. “We have not changed those things, and our students are doing just fine.”

Dr. Anne Barger, a clinical professor in veterinary clinical medicine at the University of Illinois College of Veterinary Medicine, said she stands behind the curriculum at the veterinary college.

“Students are still in the clinic and participating in clinical rotations,” she said. “By the time they're ready to graduate, we make sure they're ready. I don't think a university lets a student pass through without being confident (in the student's abilities). … Our fourth-year students are in the clinics, and they get all the experience they normally would but in a smaller group, with remote rounds, too, but they still do surgery and deal with patients.”

Veterinary colleges have used many tools to adapt during the pandemic, such as investing in various lecture-capturing systems, adopting a hybrid curriculum that breaks students into smaller groups for in-person learning and clinical training, and using online discussion forums to engage students.

HIRING NEW GRADUATES

Dr. Jodi A. Korich, associate dean for education at Cornell University College of Veterinary Medicine and 2020–21 chair of the AAVMC Academic Affairs Committee, said employer concerns about hiring new graduates are unwarranted.

“Student exam performance has actually improved, in my personal experience, and our fourth-year students on clinical rotations are actually outperforming previous cohorts,” she said. “Veterinary students are intelligent and resourceful. They have worked very hard to be admitted to veterinary college, and I believe this same work ethic and drive will carry them successfully through the pandemic. Veterinary students trained during the pandemic will continue to be well prepared upon graduation, but will have also acquired strong resiliency skills.”

Dr. Danielson agrees. He said the pandemic may make new graduates even more ready to enter the profession.

“This whole pandemic and everyone's response has been a seasoning and maturing experience for everybody, and that includes our students,” he said. “If I were an employer and able to get a great student coming out of this class, I would jump on it. I would know I have someone that is good at adapting and that's what you want out of an employee. I know what I am getting.”

WHAT'S AHEAD

While there have been improvements in several areas, some students who are just beginning their veterinary education are concerned, too.

Dr. Barger spoke to a few who have mentioned being nervous, but she said they're adjusting.

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Dr. Yuki Nakayama (right) teaches veterinary students at the Luke and Lily Lerner Spay/Neuter Clinic at Cummings Veterinary Medical Center at Tufts University on Nov. 17, 2020. (Photo by Alonso Nichols/Tufts University)

Citation: Journal of the American Veterinary Medical Association 258, 6; 10.2460/javma.258.6.547

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“I think they'll feel better once they get to the clinic and it starts to click together,” she said. “I've been blown away by how patient and resilient our students have been. There is a feeling that we are all in this together. Their dedication to this profession is inspiring. They're willing to do whatever it takes to get this done, and so are our faculty and staff. It is an amazing time for our profession.”

INTERNSHIPS VERSUS PRACTICE

Dr. Laurie Mangeli is a 2020 graduate of Tuskegee University College of Veterinary Medicine who is working at a small animal veterinary hospital in Nevada. She said during the panel that she was torn between doing an internship and going into practice.

“I was very interested in surgery and internal medicine,” she said. “I was not sure about finances, and it took a bit of thinking. I found a hospital where I could get the mentorship in surgery and the medical aspect so I can expose myself to it and figure out what I have a passion for. I found it wiser to be able to learn in the field before pursuing an internship.”

Dr. Perry Koehler, who graduated last year from Cornell University College of Veterinary Medicine, said during the panel that he was positive he wanted to do a residency. Dr. Koehler is a small animal rotating intern at the University of Florida, and he wants to go into anesthesia.

“If you don't want to do it, this atmosphere is likely not for you,” Dr. Koehler said. “If your goal is to stay in general practice, you will get better in private practice learning with a GP vet.”

Dr. Kyre Larrabee graduated from Oklahoma State University College of Veterinary Medicine in 2020 and is now an intern at an equine hospital in Colorado. She told JAVMA News that new veterinary graduates should think about their core values when choosing a place to work.

“During your time in veterinary school, you will visit many clinics and work with several veterinarians,” she said. “Use this time to your advantage. I chose to work at a practice that had similar values to what mine were when it came to work-life balance, client and patient care, and mentorship.”

FIRST DAY

Dr. Larrabee said that before her first day, she was nervous but excited. She suggests new veterinarians who are preparing for their first day get a good night's sleep and eat breakfast.

“Many people will be using their first day to get a routine established and finding their way around the clinic or hospital,” she said. “You might even already have an appointment scheduled for you on the first day, and in that case, be prepared for your first client to call you doctor for the first real time. It certainly took me by surprise.”

Several of the panelists agreed with how difficult or strange it was to introduce themselves.

“I had to remind myself that I needed to introduce myself as a doctor,” Dr. Mangeli said during the panel.

Dr. Koehler had a different perspective about his first day because he had to start teaching students.

“I've been a doctor for 45 minutes, and now I am going to teach you something,” he said during the panel. “It was a little awkward, but it has gotten easier. … You know way more than you think you do. It is in your head, and you know who to ask to find answers. It is a time thing. You are going to struggle with it, but it passes. I am six months in, and I am still confused all the time, but I feel a lot better about it.”

ADDITIONAL ADVICE, RESOURCES

The panelists suggested the following advice and tools for new graduates:

• Talk to the other doctors in the practice or people with whom you graduated if you need help or have a question.

• Use the Veterinary Information Network's simulator of student loan repayment, watch the VIN Foundation's “Climbing Mt. Debt” videos with Dr. Tony Bartels, and try using a budgeting app such as Mint.

• When interviewing for a job, ask yourself, “If I have to come to this person and tell them I screwed up, how comfortable would I be to do that?”

• Consider how practitioners are paid within a practice. If pay is production based, it could affect the amount of mentorship you receive.

The full SAVMA panel is available at jav.ma/recentgrad.

STARTING FROM SCRATCH

Of course, ordering a mask-manufacturing machine from China during a global pandemic, especially given the political turmoil between the U.S. and China at the time, came with inherent difficulties.

One hurdle was the language barrier. He teamed up with the owner of a local Chinese restaurant to translate for him while he talked to an engineer in China. He asked the engineer to build and ship a machine to make the masks.

Another obstacle was price gouging. When Dr. Conner first ordered the machine, it was to arrive at the end of last March. But then he found out the price had increased by $100,000, so he refused delivery.

“Even though I had a signed contract, the price would jump, often twice the amount,” he said, because of competition from people in Saudi Arabia or Europe who would offer more money. “It was demoralizing every time it would fail.”

Four machines later, Dr. Conner and his business partners finally received one this past October. It came in 12 gigantic crates.

“When it arrived, we stared at the parts like, ‘What have we done?‘ There were several times I was way outside my comfort zone.”

They not only had to work out the differences between Chinese and U.S. electrical systems but also figure out how to put the machine together and learn how to start it. After talking to engineers in China and furiously searching the internet, they got the machine up and running in early November. It can make 4,000 masks an hour. They hired eight community members who had lost their jobs to run the machine as well as package and ship the masks. They formed The Masketeers LLC and set up a website at american95masks.com.

“If we can sell high-quality masks and make a good business of it, we're determined to do it,” Dr. Conner said, but as he's found during this process, it's not that simple.

In a Catch-22 situation, Dr. Conner says he's been told to not market to the public because government officials have hoped to reserve supplies for front-line and health care workers. Yet, experts are increasingly saying better face coverings are needed to curb more-transmissible strains of SARS-CoV-2, the virus that causes COVID-19, as vaccine rollout is underway.

He says the right mask has to be wearable, comfortable, and breathable and has to seal to your face. It should also block 95% or more of particles.

For their masks, Dr. Conner and his partners found some U.S.-based companies making filter material less than 0.3 microns thick for the outer layer. In addition, the masks have an inner layer of hydrophilic material that wicks moisture away from your face.

“I see all these public figures wearing the wrong mask. Then I read in the national news how they don't want everyone to wear N95 masks so they can be available to first responders, but I do think for the general public, we do need to produce the correct masks to protect,” Dr. Conner said.

He's encouraged by the executive order from President Joe Biden in late January that pushes the federal government to buy more American-made goods, but Dr. Conner also knows that likely means buying from much larger companies than his.

“People pat us on the back, but as far as the federal or state government, no one seems to know or care we exist. Sadly, the most good we're doing is local and around the state,” although they have sold to buyers as far away as Australia and Germany.

He's received numerous calls from people who want to buy masks nearly at cost with the intent to raise the prices and sell to the public.

“They are profiteers,” he said. “This isn't a great time to be an opportunist, it's a great time to be a good person.

“We're just a bunch of misfits trying to help the world, trying to figure out the bureaucracy.”

BACK IN THE OFFICE

Meanwhile, Dr. Conner still runs his two clinics with a total of 40 employees, including seven associate veterinarians. None of the veterinarians has tested positive for SARS-CoV-2. He said he's been fully staffed the entire time, with no major absences, because of his insistence from the start that the staff wear proper N95 masks.

His clinic's first positive case among staff members came in May. The local public health department initially told Dr. Conner that everyone had been exposed, and the clinic would have to shut down. But when he told them about the N95 mask usage and other precautions his clinic had taken, “They told me I was doing more than the local hospital and that we could stay open,” Dr. Conner said.

The clinics partially opened their lobbies in November, when it got colder, but continue to observe social distancing and limit the number of clients who can come in, disinfect after each patient, and have everyone use hand sanitizer and wear an N95 mask.

“We're tired. There's a lot of fatigue that goes with it. And uncertainty. One vet tech's grandfather is in the hospital and is not expected to make it. Another technician has a grandparent sick in a nursing home. Both are COVID related. Our kennel manager just got back from a 14-day quarantine because she was sick with the coronavirus along with her husband. She said it was horrific how sick she was. We've all been worried about her.” She had picked up the virus during a social event at home.

During the pandemic, Dr. Conner has taken his employees on a kayak trip, and he even rented out a theater for everyone to watch a movie—while social distancing, of course.

“When you get in a high-pressure, different environment like this, what happens is you forget these are your friends and fellow soldiers in the foxhole. … We're trying to find creative ways to enjoy each other's company outside of work.

“Oddly enough, we grew during the pandemic. We had to push customers from the lobby, but even then we grew because customers knew we were going to take care of them.

“We're in the South, and some people would come in and say they're not going to wear a mask. One thing I told them was the virus is not political. It could not care less how you feel about a party. It is a virus, and all it does is seek a host.”

ONE HEALTH NOW

The COVID-19 pandemic confirms what one-health advocates have been saying for years: Multidisciplinary collaborations among veterinarians, physicians, and public health professionals are necessary to address the growing public health threat associated with zoonotic diseases.

SARS-CoV-2 is just the latest in a growing list of viruses that have spilled over from animal hosts into human populations. Most emerging infectious diseases over the last several years have been, in fact, zoonotic in nature: West Nile virus infection, avian influenza, monkeypox, severe acute respiratory syndrome, Middle East respiratory syndrome, and now COVID-19.

Dr. Bruce Kaplan, co-founder of the One Health Initiative team and website, can imagine several potential nightmare scenarios involving these pathogens. One such scenario involves Nipah virus. Although a small number of Nipah virus outbreaks have been reported in Asia, the World Health Organization has identified the virus as a priority disease for WHO research.

“This dreadful disease can spread from bats to pigs and then to humans and has a mortality rate of between 40% and 75%,” Dr. Kaplan said. “There are, of course, many other zoonotic disease candidates that have emerged and more that shall emerge in the future.

“The very real threat from these zoonotic diseases is practically shouting at us that a one-health approach is essential,” he added.

VETERINARIANS IN ACTION

A paradigm shift was underway well before the COVID-19 pandemic. In 2009, the Centers for Disease Control and Prevention became the first—and, so far, only—federal agency to establish an office dedicated to one-health activities, both domestically and globally. The current director, Dr. Casey Barton Behravesh, said the CDC office has been involved with the federal response to the COVID-19 pandemic since the start. The office created and chairs the One Health Federal Interagency COVID-19 Coordination Group, comprising 20 federal agencies across multiple departments.

Additionally, the office guides domestic and global strategy and priorities on the one-health aspects of the coronavirus, including surveillance and testing for SARS-CoV-2 in animals; consultations with and technical assistance for state, local, federal, and other partners; conducting and supporting research to better understand transmission dynamics between people and animals; and developing guidance to keep people and animals safe and healthy.

“We are still learning about the virus that causes COVID-19, and more studies are needed to understand if and how different animals, including pets, could be affected by COVID-19 and the implications this could have for human health,” Dr. Barton Behravesh explained. “To help fill the gaps in our knowledge of SARS-CoV-2 in pets, CDC, USDA, state public health and animal health officials, and academic partners are working in some states to conduct active surveillance of SARS-CoV-2 in pets, including cats, dogs, and other small mammals, that had contact with a person with COVID-19.

“These animals are being tested for SARS-CoV-2 infection and also tested to see whether the pet develops antibodies to this virus. This work is being done to help us better understand how common SARS-CoV-2 infection might be in pets as well as the possible role of pets in the spread of this virus.”

Before the pandemic, several federal agencies had endorsed the one-health concept, including the Fish and Wildlife Service, Food and Drug Administration, and Food Safety and Inspection Service. Yet, there's a sense in Washington, D.C., that these programs are not coordinating their efforts.

Dr. Kurt Schrader, a veterinarian and a U.S. representative from Oregon in Congress, attempted to tear down these silos in 2019 with bipartisan legislation that he introduced with his veterinary colleague, Dr. Ted Yoho, who has since retired from Congress. The Advancing Emergency Preparedness Through One Health Act (HR 3771/S 1903) would require the U.S. Department of Agriculture and Department of Health and Human Services to work with other departments and relevant agencies on a national one-health framework to coordinate federal one-health activities.

Although the bill didn't make it out of committee, Dr. Schrader is expected to reintroduce the measure during the new Congress, which may be motivated to act on it and similar legislation in light of the pandemic.

ON THE FRONT LINES

Veterinary medicine is a public health profession, although it can be less obvious for veterinarians not directly involved in epidemiology, food safety, toxicology, and research on infectious diseases. The SARS-CoV-2 outbreak may have changed that, as veterinarians across all sectors stepped up to respond to the COVID-19 pandemic.

Veterinarians were essential in understanding how the novel coronavirus affected animal populations, including livestock and pets. They spoke to the news media and reassured the public about how studies so far show no animal species transmits the novel coronavirus to humans, with the exception of the unidentified source and possibly farmed mink.

“Veterinarians have been on the front lines, educating pet owners and members of the public in addition to serving in local, state, and federal public health departments to combat this pandemic,” said Dr. Donna DeBonis, president of the American Association of Food Safety and Public Health Veterinarians.

This past October, the AAFSPHV honored veterinarians worldwide with the 2020 Food Safety and Public Health Veterinarian of the Year Award for their work before, during, and after the pandemic.

“Since the start of the pandemic, we have seen an increase in the interest in veterinary public health and anticipate the roles and opportunities for veterinarians will continue to increase,” Dr. DeBonis added.

Governors across the nation declared veterinary practices an essential service, allowing practices to remain open as much of the country went into lockdown. Veterinarians showed their adaptability no matter what segment of the profession they were in. While some veterinarians were dealing with market disruptions and working to ensure a safe and uninterrupted food supply, others were caring for horses, laboratory animals, zoo animals, and pets. All adapted their workplaces in some way to protect their teams while continuing to provide care for animals and services for clients.

The emotional bond between people and their pets during the pandemic is a subject of interest to many researchers. Early studies found pets had a positive influence on the owner's mental health during this especially stressful time. For example, a study of Australian pet owners published July 2020 in the International Journal of Social Psychiatry found that pets made isolation easier, reduced loneliness, and increased companionship during the lockdown.

‘PREPARE TO TAKE A BEATING‘

As the COVID-19 pandemic stretched from days to weeks to months to a year, it became apparent that pubic health can be controversial.

Public officials were pilloried for shuttering large parts of society, including stores, schools, and sports venues; for requiring masks be worn in public; and for limiting or canceling social gatherings. The most public face of the nation's handling of the pandemic, Anthony Fauci, MD, director of the National Institute of Allergy and Infectious Diseases, was one of several public health officials who received death threats.

“The inherently controversial nature of public health is caused by a constant tension between collective responsibility and individual behavior,” explained Dr. Donald Noah, a veterinary epidemiologist who has been deputy assistant secretary for the Department of Defense and Department of Homeland Security.

Currently, Dr. Noah is an associate professor of public health and epidemiology at the Midwestern University College of Veterinary Medicine. Public health, he explained, is at its best when it's apolitical. Problem is, it never is.

“I tell my students, ‘Prepare to take a beating,‘ because one thing we should always strive to do as public health veterinarians is have an opinion—one based on evidence-based research that you can argue in a way that's collegial without spiraling into name-calling, which ends up being counterproductive,” Dr. Noah said.

On the point about the difficulties of communicating potentially controversial health information to the public, Dr. Hungerford believes veterinarians have an advantage over their colleagues on the human side of medicine.

“Most of us in veterinary medicine work directly with communities, and we understand no one likes to be told what to do or that we know better than the client,” Dr. Hungerford explained. “Listening and valuing where others are coming from is necessary to work toward a common good. As veterinarians, we know this, I think more so than many health professionals.”

VACCINES FOR VETERINARIANS

“The rollout has been really challenging for those waiting to be vaccinated,” said Dr. Gail Golab, AVMA chief veterinary officer. She was speaking during the webinar “COVID-19 Update: Veterinarians and Vaccines” available via AVMA Axon, the AVMA's online platform for continuing education and other offerings.

In September 2020, the AVMA provided comments to the National Academies of Sciences, Engineering, and Medicine on the “Discussion Draft of the Preliminary Framework for Equitable Allocation of COVID-19 Vaccine.” The draft helped inform the CDC's “COVID-19 Vaccination Program Interim Playbook for Jurisdiction Operations.”

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Then, in January, the CDC Advisory Committee on Immunization Practices mapped guidance from the Cybersecurity and Infrastructure Security Agency, which identified essential critical infrastructure workers, to corresponding vaccination phases. Throughout the pandemic, Dr. Golab said, the AVMA has been providing input to CISA, encouraging the agency to recognize veterinarians in all types of practice as essential critical infrastructure workers.

“So when the rollout phases were mapped from those CISA guidelines, those providing veterinary services were specifically and discretely recommended for inclusion by the CDC in Phase 1b, and this was a hugely important federal win for veterinary medicine,“ Dr. Golab said. ”It is important to recognize, however, that final decisions about priorities for administration of COVID-19 vaccines are actually being made at the state and territorial level, so vaccine availability for veterinary personnel is going to vary by location.“

Dr. Golab said state and local VMAs have been working hard to support veterinary teams' access to COVID-19 vaccines. The AVMA has been assisting by providing information about federal developments as well as talking points and communication support.

VETERINARIANS HELPING WITH THE VACCINATION EFFORT

Most of APHIS' deployed employees will help vaccinate people in Nevada and Oklahoma. The agency sent eight employees to Texas to help manage resources for a vaccination site. The agency also virtually deployed six employees to assist Washington state in planning vaccination efforts, four employees to assist Oregon, and nine employees to support the Federal Emergency Management Agency.

The AVMA was aware that at least four states—Colorado, Connecticut, Nevada, and Ohio—had begun to include veterinary personnel in their vaccination delivery plans. The role of veterinarians in these plans varies.

“Interest on the part of some veterinarians is understandable, because the profession often responds to disasters and we naturally want to help,” according to the AVMA's FAQ on COVID-19 vaccination.

The FAQ advises keeping in mind the following:

• Veterinarians should not expect their veterinary malpractice insurance to cover them for human injury arising out of the administration of vaccines to people.

• Veterinarians are not explicitly addressed in the federal Public Readiness and Emergency Preparedness Act or the current declarations under it that provide limited immunity from liability arising out of, relating to, or resulting from administration or use of countermeasures, such as the COVID-19 vaccine.

• There may be state-specific laws that provide immunity. They may need to be predicated by some emergency finding or declaration, and there may be specific requirements for veterinarians to be covered.

RISK POTENTIAL IN ANIMALS

Tufts University virologist and disease ecologist Dr. Jonathan A. Runstadler leads a team in the Cummings School of Veterinary Medicine that began collecting SARS-CoV-2 samples in February 2020, at first working to determine whether the staff at the teaching hospital risked exposure through pets. His long-term goal is to understand how the virus could spill back and forth between species.

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Veterinary staff members at the Cummings Veterinary Medical Center at Tufts University swab the mouth of a pet ferret for SARS-CoV-2 epidemiological research. (Courtesy of Tufts)

Citation: Journal of the American Veterinary Medical Association 258, 6; 10.2460/javma.258.6.547

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As of early February, his team had collected about 3,200 samples from 1,700 animals, a combined total of nasal, oral, and anal swabs as well as serum samples. About 2,000 of those samples came from dogs or cats, and the rest came from another 63 species of nearby bats and other wildlife in New England and zoo animals.

“It's a good thing that we haven't really seen spillover in ways that we thought might be possible, particularly as the pandemic spread among the human population” and the virus became more widespread, he said.

But COVID-19 remains an emerging disease, and Dr. Runstadler sees a responsibility as part of a veterinary school and the veterinary profession to maintain surveillance in animals and to work to end the pandemic.

“We've got veterinarians here and elsewhere who are doing really critical work on animal models and animal model development and working on vaccine development,” he said.

USDA Animal and Plant Health Inspection Service officials catalogue reports on animals with confirmed positive tests for SARS-CoV-2 infection. As of Jan. 15, animals had been infected in at least 131 incidents, 58 of them involving domestic cats and 41 involving dogs. Although only 16 incidents involved mink, those outbreaks sickened and killed unknown numbers of animals on farms in Michigan, Oregon, Utah, and Wisconsin.

So far, mink have been the only farmed animals known to be susceptible to SARS-CoV-2 infection, and a mink captured and tested near a farm in Utah remains the only wild animal positive for the virus, APHIS officials said.

Emma Moran, PhD, a biological science specialist who has led a COVID-19 rapid response program for the USDA National Institute of Food and Agriculture, said the agency issued two $1 million grants to fund research projects at veterinary colleges to examine potential SARS-CoV-2 replication and mutation in pig, chicken, and cattle cells and to examine beef cattle susceptibility and viral contamination in food processing. Another $350,000 grant is funding studies on potential susceptibility and transmission in deer and elk.

Mark Mirando, PhD, who is a biological science specialist for NIFA, national science liaison for animal production systems, and science coordinator for the NIFA Agriculture and Food Research Initiative, said NIFA has other grants available in case SARS-CoV-2 variants become greater threats to livestock. And he noted that NIFA and APHIS fund the National Animal Health Laboratory Network that is supporting research into potential infections across animal species.

MAKING THE NEXT VACCINE

The work in veterinary colleges extends to developing the next generation of human-use COVID-19 vaccines.

Mary Jackson, PhD, a bacteriology professor in the Mycobacteria Research Laboratories and Department of Microbiology, Immunology, and Pathology at Colorado State University College of Veterinary Medicine & Biomedical Sciences sees potential to adapt an existing vaccine against tuberculosis as a vaccine against SARS-CoV-2.

The recombinant COVID-19 vaccine would be based on the century-old bacillus Calmette-Guerin tuberculosis vaccine. The BCG vaccine has been known for decades to improve immunity against viral pathogens and reduce illnesses and deaths among children and the elderly, and recent epidemiologic studies suggest potential to reduce the prevalence and severity of COVID-19 symptoms, according to project information filed with the National Institutes of Health, which is providing $412,000 toward the project.

Dr. Jackson said she sees potential to use the vaccine as a platform for a new vaccine that expresses specific antigens of SARS-CoV-2.

“We are testing multiple constructions, and I would say we have more than 12 right now that we are exploring,” Dr. Jackson said.

Veterinary researchers at the University of Wisconsin-Madison and The Ohio State University are developing vaccine candidates adapted from influenza and measles vaccines, respectively, according to university announcements. Others at Colorado State are collaborating on studies to use ultraviolet light and riboflavin to create an inactivated virus for a COVID-19 vaccine candidate, and Purdue University veterinary scientists are developing an adenovirus-based vaccine platform.

Company officials for Applied DNA Sciences announced in November plans to conduct clinical trials on feline-use vaccine candidates against SARS-CoV-2 infection, in collaboration with EvviVax and Guardian Veterinary Specialists.

Robert Weiss, PhD, said researchers at the Cornell University College of Veterinary Medicine have pursued studies in not only vaccine development for human medicine but also diagnostics, assays of host antibodies in serum and saliva samples, therapeutics to impair viral transmission and replication, and fundamental understanding of the mechanisms used by SARS-CoV-2, in addition to the work by the state veterinary diagnostic laboratory housed in the veterinary college to test about 5,000 COVID-19 samples from students daily.

Collaboration between the veterinary college and Cornell Engineering, for example, is helping disease experts image the SARS-CoV-2 virus, understand its structure, and potentially see weaknesses to exploit, he said.

STUDYING A VIRUS, APPLYING THE ONE-HEALTH CONCEPT

Dr. Rebecca Lee Smith, a veterinary epidemiologist and associate professor of epidemiology at the University of Illinois College of Veterinary Medicine, started work in spring 2020 on a team that decided whom to test at the university, how often to test, what messages to send out, and how to coordinate quarantines. She studies incoming data from the 10,000 COVID-19 tests processed by the Veterinary Diagnostic Laboratory each weekday and 45,000 processed each weekend, and she talks with other health leaders on and off campus about what interventions are working and what's needed.

She also leads work on a monthly survey that asks all the people on campus about their activities and perceptions of risk, with goals of identifying what makes people more likely to test positive for SARS-CoV-2 and developing messages to encourage better behavior.

“A lot of the work that I do, although it's very much in the human realm, I'm bringing in things that are very common in veterinary epidemiology and are not well known in human epidemiology,” Dr. Smith said. “So, thinking about risk-based surveillance, which we do in livestock fairly frequently, that isn't something you see in human epidemiology.”

Adjusting the frequency of COVID-19 testing based on risk calculations, for example, helped U of I control pockets of infection. One ongoing study examines how to minimize the frequency of testing in humans yet maximize sensitivity to infections, adapting techniques developed to minimize stress in zoo populations, Dr. Smith said.

“Veterinary epidemiologists in particular really should step up and help here because we have a lot of experience within the realm of infectious disease control—and with limited resources,” Dr. Smith said.

Dr. John Middleton, who is a professor of food animal medicine and surgery at the University of Missouri College of Veterinary Medicine and chair of the AVMA Council on Research, is working with colleagues in the university's schools of medicine and health professions to study links among infections, perceptions, and mitigation efforts, among other projects.

“These emerging viral threats potentially come from animals, and so veterinarians have a role and veterinary colleges certainly have a role in helping us understand these diseases,” he said. “And I think you'll find there are experts in veterinary schools who understand coronavirus and, therefore, that is certainly helpful in allowing us to understand this coronavirus.”

Isaac Pessah, PhD, associate dean and professor of molecular biosciences at the University of California-Davis School of Veterinary Medicine, described the pandemic as a hallmark moment for veterinarians working in the one-health area, especially for those working on viral infectious diseases. Past research into infectious immunologic disorders shows the benefits of interdisciplinary approaches, embracing the study of diseases in animals to understand their effects in humans, Dr. Pessah said.

The one-health concept, once nebulously defined, is gaining acceptance as diseases emerge, a problem that rises in frequency with additional human incursions at wildlife boundaries.

“(Such a) disease isn't necessarily going to stay local, as we now know with COVID-19,” Dr. Pessah said. “It can go global very quickly. And although we think we're ready and able to deal with it—wow, obviously not good enough, with all of our technology.”

Dr. Udeni B.R. Balasuriya, director of the Louisiana Animal Disease Diagnostic Laboratory and professor of virology at the Louisiana State University School of Veterinary Medicine, collaborates with Dr. Richt on studies to develop animal models to test antiviral drugs and vaccines and collaborates with U.S. Geological Survey scientists who are studying SARS-CoV-2 susceptibility in North American bats, among other studies he and colleagues have been conducting or aiding through the diagnostic laboratory. The pandemic showed veterinary laboratories' capacity to process large numbers of samples for human medicine, he said.

“We have a major role in public health, but we are not that recognized,” he said.

Dr. Maccabe of the AAVMC said people will need to remember the importance of supporting veterinary research as the world emerges from the pandemic.

“There is a great deal of capacity at our veterinary medical colleges, and we need to preserve and protect that capacity,” he said.

SURVEY SAYS

Dr. Michael Longoni, medical director of Diamond Veterinary Hospital in Everett, Washington, remembers well the early shock of the pandemic. He and his practice manager, Angie Koellner, were already preoccupied, going through a corporate transition, when news of COVID-19 hit. Gov. Jay Inslee started issuing directives in February and March to shut down businesses and preserve personal protective equipment.

Dr. Longoni's clinic stopped all routine procedures, including spays, neuters, and dentals, and even cut back on vaccinations for the first two months. The clinic paused routine procedures again briefly when a second wave of COVID-19 hit following the holidays late in 2020.

The practice came close a few times but never ran out of PPE thanks to being more conservative with the number of routine procedures scheduled, once the practice was able to resume performing them.

“The hardest thing is inventory. Our inventory person knew it would be a challenge” to procure items, particularly when the price would increase 200% from when the practice last bought them, Dr. Longoni said. “In the middle of a pandemic, how do you stay price viable?”

Overall, the AVMA survey findings from April show a large number of veterinary practices had decreases in several key areas during the survey period, including client traffic, operating hours, and revenue.

Combining survey results from April and June, however, 46% of practices reported revenue increases of 1% to 25% in 2020, compared with 2019. A similar percentage of practices reported a year-over-year 1% to 25% increase in expenses. Twenty-eight percent of survey respondents experienced no change in revenue between 2019 and 2020, while 20% saw revenue drop by 1% to 25%.

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FACTORS IMPACTING PRACTICES' MONTHLY CASH FLOW, APRIL 2020

Citation: Journal of the American Veterinary Medical Association 258, 6; 10.2460/javma.258.6.547

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IMPACT OF COVID-19 ON REVENUE BY PRIMARY FOCUS OF THE PRACTICE, APRIL 2020

Citation: Journal of the American Veterinary Medical Association 258, 6; 10.2460/javma.258.6.547

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A veterinary staff member escorts Trouble the dog into Diamond Veterinary Hospital in Everett, Washington, which switched to curbside service early in the pandemic. (Courtesy of Dr. Michael Longoni)

Citation: Journal of the American Veterinary Medical Association 258, 6; 10.2460/javma.258.6.547

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Cash shortfalls—when a business's financial obligations exceed the amount of available cash—averaged $17,000 for veterinary practices in April and $14,000 in June. In April, most practices (61%) accounted for the shortfall at least partly with loans from the Small Business Administration, but by June that number had fallen to 39%.

ADAPTATION

Today, Dr. Longoni is still worried about social distancing and keeping staff members safe. The practice had to add another overnight staff member and has sometimes stopped seeing more emergency cases until the staff catches up, except for certain critical cases.

Even now, with COVID-19 cases decreasing, Dr. Longoni is left wondering whether to start doing more again and switch back to “normal.”

“Angie and I have talked. With the volume of our practice the way it is, we are not anxious to go back to noncurbside. Even once other practices start to go back and the governor implies you can, we're probably going to be late to that game. We had just gone through a remodel the year before, which allows for more space, but social distancing in veterinary medicine is almost an oxymoron,” he said.

Like Diamond Veterinary Hospital, many practices implemented a wide range of operational strategies and precautionary measures to continue providing veterinary care while working to limit the spread of the coronavirus.

The most common approach was asking clients to wait in their vehicles during examination and treatment of their animals. Other operational changes included contactless payment processing, taking patient histories by phone or virtually, and drive-thru pickup and drop-off.

Between April and June, a small number of practices reduced many of these approaches. For example, in April, 84% of respondents asked clients to wait in their vehicles during treatment; by June, that number dropped to 73%. The number of practices implementing contactless payment processing and taking patient histories by phone or virtually also declined during that time. In contrast, the percentage of practices taking client visits only by appointment increased from 56% in April to 75% in June.

The number of veterinary practices that reported using telemedicine in April and June remained constant at 32%. Eighteen percent of practices only saw emergency-related cases at the time of the second survey, down from 20% reported in the first survey.

MAKE A PLAN

One of the key takeaways from the AVMA report, according to Dr. Weinstein, is preparation. Every practice owner should plan for long-term emergencies.

“Make sure you have some operational funds put away, a rainy day fund that's invested but liquid so, if for some reason you have to shut down, you can still pay your staff, your bills, and so on,” Dr. Weinstein explained.

Telemedicine and other web-based innovations, such as online pharmacies and pet food delivery, are ways a practice can continue generating income even when the building is closed, he said. And if a practice must close, the practice should keep clients updated via its website and social media.

EVENT

129th annual convention, held virtually, Jan. 21–24

PROGRAM

Registration for the convention included 291 members and 57 veterinary clinics. In excess of 80 virtual continuing education lectures were offered to the more than 950 CE registrants. The lectures will be available until April 30.

AWARDS

Veterinarian of the Year

Dr. Steve M. Strubberg (Missouri '89), New Haven. Dr. Strubberg has served as Missouri state veterinarian since 2019. Prior to that, he owned Hermann Veterinary Clinic, a mixed animal practice in Hermann, for almost 30 years.

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Dr. Steve M. Strubberg

Citation: Journal of the American Veterinary Medical Association 258, 6; 10.2460/javma.258.6.547

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President's Award

Dr. Missy Gourley (Missouri '96), Mountain Grove. Dr. Gourley practices small animal medicine at Whetstone Veterinary Clinic in Mountain Grove.

Ortu Stella Award

Dr. Jessica Stroupe (Missouri '12), Fayette, won this award, given for early-career leadership. Dr. Stroupe owns Howard County Veterinary Service in Fayette. She is a past president of the West Central VMA and is a member of the Women's Veterinary Leadership Development Initiative.

William A. Wolff Volunteerism Award

Abbie Knudsen (Missouri '22), Auxvasse. Knudsen was recognized for organizing a pet food drive during the pandemic. She is co-founder of the Missouri Coalition of Animal Care Organizations and Midwest Animal Sheltering Conference. Knudsen has served as executive director for the National Tiger Sanctuary in Saddlebrook.

Missouri Veterinary Medical Foundation Distinguished Service Award

Lori Muhlenbruch, Lake Ozark. Muhlenbruch is program coordinator for the MVMA. She is responsible for programs within the Missouri Veterinary Medical Foundation, including the Veterinary Honor Roll and Animal Archives. Muhlenbruch also serves as a staff member for the MVMF Board and Missouri VMA Academy.

Missouri VMA Academy Distinguished Service Award

Dr. Richard Linn (Missouri '83), Ozark. Dr. Linn owns Ozark Veterinary Clinic. He is active with the Christian Veterinary Mission and the 4-H Club Veterinary Science Program and is a member of the Missouri Volunteer Veterinary Corps.

OFFICIALS

MVMA—Dr. Marcy Hammerle, St. Charles, president; Dr. Edward Migneco, St. Louis, president-elect; Dr. Matt Silvius, Riverside, vice president; Dr. Shelia L. Taylor, Springfield, secretary-treasurer; Dr. David L. Gourley, Mountain Grove, board chair and immediate past president; and Richard D. Antweiler, Jefferson City, executive director. Missouri VMA Academy–Drs. Caitlin DeWilde, St. Louis, president; Betsy Marziani, St. Louis, vice president; and Julie King, Ozark, immediate past president. MVMF—Drs. Philip R. Brown, Springfield, board chair; Scott Fray, Boonville, board vice chair; George Buckaloo, Lake Tapawingo, secretary-treasurer; William J. Shore, St. Louis, immediate past chair; and Roger Dozier, Jefferson City, museum director

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Dr. Marcy Hammerle

Citation: Journal of the American Veterinary Medical Association 258, 6; 10.2460/javma.258.6.547

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