Introduction

Tularemia is a zoonotic disease caused by the gram-negative bacteria Francisella tularensis. In the US, rabbits and rodents are the most widely recognized reservoir in nature, but a diverse population of species can be infected. Among domestic animals, cats, dogs, and sheep most often develop clinical disease, and tularemia can cause severe illness in people. Transmission to people and animals can occur in various ways, including via bite from an infected tick, most often Amblyomma and Dermacentor species; deerfly bite; direct contact with infected animals; ingestion of contaminated food or water; or aerosolization and inhalation of the bacteria.¹ Because of its low infective dose (requiring as few as 10 organisms to cause disease), aerosol transmission, and bioweapon history, F tularensis is considered by the CDC to be a Tier 1 select agent.² There are currently 68 select agents and toxins designated by the Department of Health and Human Services and USDA because of their potential to pose a severe threat to public health and safety, animal or plant health, or animal or plant products; 13 of these biological agents are considered Tier 1 because they present the greatest risk of deliberate misuse, with significant potential for mass casualties and devastating effect on the economy, critical infrastructure, and public confidence.^2,3

The incidence of tularemia in people has been increasing in the US, nearly doubling from 0.04 to 0.07 cases per 100,000 person-years from 2001 through 2010 to 2010 through 2020, respectively.⁴ This increase is likely due to a combination of changes in climate, tick range expansions, habitat and land use changes, and host population dynamics.⁵ United States tularemia incidence is highest in the central plains, likely due to the high prevalence of the lone star tick (Amblyomma americanum) and American dog tick (Dermacentor variabilis).⁵ From 2011 to 2019, Kansas had the fourth highest incidence of tularemia, with 10.3% (205 of 1,984) of all US cases, following Arkansas (18.9% [374 of 1,984]), Missouri (12.1% [241 of 1,984]), and Oklahoma (11.0% [218 of 1,984]).^4,6 In 2022, Kansas had the highest incidence of human tularemia cases reported in the US, with 0.9 cases per 100,000 residents, followed by Nebraska (0.7) and Arkansas (0.5).⁶ Although human cases of tularemia are reportable, tularemia is not reportable from animal species in Kansas, and the incidence in Kansas pets is unknown.⁷

With the comparatively high incidence of human tularemia cases in Kansas, the risk to and the role of veterinarians and their teams in this One Health system require further understanding. One Health refers to the dynamic interplay between human, animal, and environmental health and recognizes that a transdisciplinary, systems-based approach is fundamental to addressing complex issues facing these sectors. Tularemia is a multifaceted disease whose transmission dynamics are impacted by many different factors in the One Health continuum, including human and animal behavior and populations, natural environmental management practices, changes in the built environment, weather patterns, vector abundance, distribution, range expansion, host preferences, and many other factors. For example, individual human behavior such as lawn care practices, consumption and handling of game, and interaction with pets will affect potential exposures to tularemia. Likewise, whether pets are treated with tick prevention, allowed to hunt, or kept strictly indoors influence their potential exposure to tularemia. Veterinarians are uniquely positioned to play an important One Health role in tularemia management because of their understanding of disease-transmission dynamics in relation to wildlife species, expertise in recommending environmental tick control and tick prevention for companion animals, and care for domestic species that can be affected (ie, dogs, cats, sheep) as well as the role they play in educating their staff and clients to minimize zoonotic disease transmission.

Veterinary personnel practicing in Kansas, including veterinarians, registered veterinary technicians, veterinary assistants, and kennel workers, may be exposed to animal patients with clinical tularemia.⁸ In addition to prompt diagnosis and treatment for infected patients, veterinarians and veterinary personnel need to take precautions to protect themselves in the work environment. Additionally, veterinarians have a public health responsibility to provide client education for pet owners about precautions in the home and community (pet and environmental vector control) to protect against transmission of tularemia to both people and animals.

In this study, we surveyed veterinarians and veterinary technicians in Kansas to learn their knowledge, attitudes, and current practices with regard to the occupational risk of tularemia, use of personal protective equipment (PPE), patient diagnosis and management, zoonotic risk communication for owners, and public health reporting. Secondary objectives were to identify the hurdles veterinarians face regarding tularemia management and topics for which additional education could be most beneficial.

Methods

The study was designed as a cross-sectional survey with a target population of licensed veterinarians and veterinary technicians practicing in Kansas. Unlicensed veterinary assistants practicing in Kansas were also invited to complete the survey and designated their status in the survey. A minimum of 15 participants per group (veterinarian, technician, and assistant) were required for that group to be included in the study. The survey was reviewed and considered exempt by the Kansas State University Institutional Review Board (IRB No. 12225) on the basis of the criteria that it only included interactions involving survey procedures.

The survey was created in an electronic format. It was distributed via QR code at an annual veterinary continuing education conference in Manhattan, Kansas, on June 3 to 4, 2024, and then subsequently sent by email to current and past attendees of that conference (both in person and virtually), alumni who were reported to practice in Kansas, and current faculty and staff at Kansas State University’s College of Veterinary Medicine (2,111 people). Not all who received the survey were necessarily eligible to participate, as they might not have fit the criteria of being a veterinarian, registered veterinary technician, or veterinary assistant practicing in Kansas. The survey was distributed 3 times, 3 weeks apart to attract maximum participation. Furthermore, the survey was emailed to veterinarians and technicians in Kansas known to the research team, specifically targeting technicians and veterinarians in less represented regions of the state, and encouraged to be shared via email with their contacts. Additionally, the survey was posted and shared on the researchers’ LinkedIn accounts. For reference, Kansas has 2,837 licensed veterinarians and 777 licensed registered veterinary technicians, though the number practicing in Kansas is unknown.⁹ Although we attempted to reach all licensed veterinarians in Kansas with this multimodal approach, some veterinarians and technicians might not have received the survey. A response rate was not calculated because of the inability to know the exact number of veterinarians and technicians invited to participate.

The survey was developed by the research team and piloted by 3 veterinarians in other states for clarity, with minor changes made based on suggestions. The final survey is available in Supplementary Material S1. The survey included a cover letter explaining the purpose of the survey and allowing informed consent. While most responses did not collect any personal identifying information, there was the opportunity to include a contact name and email information if the participant consented to being contacted to discuss tularemia patients they had managed in the past 5 years. The survey took a median of 5 minutes to complete and included 28 questions for veterinarians and 23 questions for technicians. All were multiple-choice questions, and some had the option for free text. Display logic was used to limit questions asked on the basis of the answers provided.

The first set of questions asked about participant demographics, years in practice, and geographic location of veterinary practice by district in Kansas, as shown in Figure 1.¹⁰ Participants were asked to describe their veterinary practice by species (companion animal exclusive, companion animal predominant, mixed animal, food animal predominant, food animal exclusive, or equine), as defined by the AVMA.¹¹

View Full Size

Geographic location, based on district in Kansas, of veterinarians and veterinary technicians (N = 128) who responded to a 2024 survey about knowledge, attitudes, and practices of Kansas veterinary personnel in the diagnosis, management, and One Health implications of tularemia in cats and dogs. NC = Northcentral. NE = Northeast. NW = Northwest. SC = South Central. SE = Southeast. SW = Southwest. (Adapted from District offices: district office regional map. Kansas Department of Health and Environment. Accessed October 24, 2024. https://www.kdhe.ks.gov/288/District-Offices. Reprinted with permission.)

Citation: Journal of the American Veterinary Medical Association 263, 5; 10.2460/javma.24.11.0725

• Download Figure
• Download figure as PowerPoint slide

The next set of questions asked whether veterinarians had ever diagnosed tularemia in a cat or dog and veterinary technicians whether they had ever helped care for a patient with tularemia. Next, participants were asked for an estimate of how many cats or dogs with tularemia they had diagnosed (or cared for) per year in the past 5 years. The standard case definition to confirm tularemia diagnosis in people is isolation of F tularensis from clinical specimens or a 4-fold rise in antibody titer; this definition is cited for companion animals as well.^1,12 There is no standard case definition for companion animals; however, the World Organisation for Animal Health includes animals in the orders Lagomorpha and Rodentia diagnosed by PCR in their case definition, as long as they are showing clinical signs or pathological lesions consistent with tularemia OR are epidemiologically linked to a confirmed human or animal case with tularemia OR antibodies to F tularensis have also been detected from the animal host.¹³ Additionally, the World Organisation for Animal Health does not require a 4-fold rise in antibody titer and includes in its case definition rabbits and rodents with any antibodies to F tularensis as long as they have clinical signs or pathological lesions consistent with tularemia OR the animal is epidemiologically linked to a confirmed human or animal case with tularemia OR there is cause to suspect the animal host has had direct contact with F tularensis.¹³ We hypothesized that some veterinarians make a presumptive diagnosis based on consistent exposure and clinical signs without any laboratory testing. As the survey was not aiming to determine true incidence but to learn about behaviors around tularemia patient management, the survey included both confirmed and suspect cases of tularemia, with suspect cases being those diagnosed on the basis of clinical signs and physical examination alone.

Participants were asked whether tularemia can be transmitted from animals to people, whether it is reportable in Kansas for animal and/or human patients, and whether they have reported previous cases to the health department. Veterinarians were further asked how often they submit diagnostic testing to confirm suspected cases of tularemia, which tests they submit, and hurdles for submission. Additionally, veterinarians were asked which antibiotic was their preferred treatment for tularemia in pets.

The third set of questions was about PPE and occupational risk of acquiring tularemia. Participants were asked what standard PPE they wear when lancing an abscess from a cat or dog or when participating in a necropsy when tularemia is not suspected. They were then asked what PPE they wear if they suspect tularemia for routine examination and basic care as well as for lancing abscesses or performing a necropsy. Participants were asked whether they themselves have ever had tularemia and, if so, what they suspected the source was, as well as whether they were aware of a coworker or pet owner who had developed tularemia. Further, they were asked whether they discuss public health implications of tularemia with pet owners and whether they document these conversations in the pets’ medical records.

Additionally, an informational cage sign was created that can be posted in veterinary hospitals to notify veterinary personnel of patients with suspected or confirmed tularemia. This sign is also designed to educate about the zoonotic risk, types of exposures, PPE recommended, and appropriate responses following exposure (Supplementary Material S2).^8,15,16

Results

The survey was completed by 109 veterinarians, 19 registered veterinary technicians, and 2 veterinary assistants. Not enough veterinary assistants participated to be included in the data analysis, and thus they were excluded. The majority (91 of 128 [71%]) considered themselves to be companion animal exclusive (at least 90% dogs, cats, nonpoultry avian, and exotics), but some predominantly small animal veterinarians and technicians as well as mixed and large animal veterinarians and technicians participated (Table 1). Participants were mostly from the North Central and Northeastern districts but represented all districts in the state (Figure 1). The majority of responding veterinarians had been practicing for > 20 years, whereas there was a more even distribution of recent graduates and experienced veterinary technicians (Figure 2).

View Full Size

Distribution of how many years each survey participant, as described in Figure 1, has been practicing veterinary medicine, including veterinarians (N = 109; dashed) and registered veterinary technicians (N = 19; solid).

Citation: Journal of the American Veterinary Medical Association 263, 5; 10.2460/javma.24.11.0725

• Download Figure
• Download figure as PowerPoint slide

Forty-three percent (47 of 109) of responding Kansas veterinarians reported having diagnosed tularemia in a cat in Kansas, whether suspected or confirmed, and 13% (14 of 109) of veterinarians reported having diagnosed tularemia in a dog in Kansas. Seven percent (8 of 109) of veterinarians reported having diagnosed tularemia in both a cat and a dog in Kansas. The frequency of tularemia cases diagnosed by each veterinarian over the past 5 years is displayed in Figure 3. Sixty-three percent (12 of 19) of technicians have cared for a cat with tularemia, and 26% (5 of 19) of technicians have cared for a dog with tularemia. Sixteen percent (3 of 19) answered that they have cared for both a cat and a dog with tularemia, and 32% (6 of 19) answered they have never cared for a cat or dog with tularemia. The frequency of tularemia cases cared for by technicians over the past 5 years is displayed in Figure 4.

View Full Size

The average number of cases of tularemia in dogs (dashed) and cats (solid) in Kansas reportedly diagnosed over the past 5 years by veterinarians who responded to the survey (N = 109), as described in Figure 1. Note that these cases may or may not have been confirmed as tularemia with diagnostic testing.

Citation: Journal of the American Veterinary Medical Association 263, 5; 10.2460/javma.24.11.0725

• Download Figure
• Download figure as PowerPoint slide

View Full Size

Average number of cases of tularemia in dogs (dashed) and cats (solid) in Kansas reportedly cared for over the past 5 years by responding technicians (N = 19), as described in Figure 1. Note that these cases may or may not have been confirmed as tularemia with diagnostic testing.

Citation: Journal of the American Veterinary Medical Association 263, 5; 10.2460/javma.24.11.0725

• Download Figure
• Download figure as PowerPoint slide

Forty-two percent (26 of 62) of veterinarians who have suspected a case of tularemia say they never submit a laboratory test to confirm the diagnosis, compared with veterinarians who always (16% [10 of 62]) or most of the time (16% [10 of 62]) submit testing to confirm tularemia. Hurdles listed for diagnostic testing included owner finances (91% [42 of 46]); being unsure of what sample to submit (20% [9 of 46]), unsure of what laboratory test to order (11% [5 of 46]), unable to collect a proper sample (9% [4 of 46]), unsure of what laboratory to submit to (7% [3 of 46]); and turnaround time (4% [2 of 46]). One respondent commented, “usually response to treatment is fast, so length of time to get results is not helpful in treatment plan.” Of those submitting laboratory tests, PCR (49% [19 of 39]) was listed most commonly, followed by antibody titer (46% [18 of 39]), culture (21% [8 of 39]), fluorescent antibody of tissue (13% [5 of 39]), and necropsy (8% [3 of 39]). Of veterinarians submitting serology, 35% (9 of 26) reported they always submit a convalescent titer, 38% (10 of 26) reported they never submit a convalescent titer, and 27% (7 of 26) said it depends on the result of the initial titer.

Fifty-eight percent (62 of 107) of veterinarians responded that they would look up the best treatment option for tularemia in cats prior to treatment, while others listed their antimicrobial treatment of choice for cats as pradofloxacin (14% [15 of 107]), followed by doxycycline (13% [14 of 107]), enrofloxacin (6% [6 of 107]), gentamicin (6% [6 of 107]), marbofloxacin (1% [1 of 107]), and amoxicillin-clavulanate (1% [1 of 107]). Similarly, 65% (70 of 107) of veterinarians responded that they would look up the best treatment option for tularemia in dogs prior to treatment, while others listed their antimicrobial treatment of choice for dogs as enrofloxacin (16% [17 of 107]), followed by doxycycline (12% [13 of 107]), gentamicin (3% [3 of 107]), and marbofloxacin (2% [2 of 107]).

When asked about PPE, all respondents said they wear gloves when lancing abscesses and performing necropsies, whether tularemia is suspected or not, and the majority (98% [118 of 121]) wear gloves for examinations and basic care for tularemia suspects (Table 2). When tularemia is suspected, technicians reported that they wear gowns more often (10 of 17 [59%]) than veterinarians (33 of 104 [32%]) for examinations and routine care (χ² = 4.682; P = .030), but no significant differences were observed between technicians and veterinarians in any other PPE category. Beyond gloves, PPE was inconsistently worn when tularemia was suspected for routine care as well as for procedures such as lancing abscesses and performing necropsies. Although not specifically asked, 5 veterinarians commented that they would not perform necropsies on tularemia suspects but would refer to a diagnostic laboratory.

When performing routine care on cats or dogs suspected to have tularemia, the only difference in PPE use by experience level was that veterinarians practicing > 20 years (1 of 48 [2%]) reported using N95 respirators less than veterinarians who were 1 to 5 years postgraduation (4 of 17 [24%]; Fisher exact test, 0.015; P < .05). When lancing abscesses or performing necropsies on cats or dogs with tularemia, veterinarians practicing > 20 years (20 of 47 [43%]) reported wearing gowns less than veterinarians practicing for 5 to 10 years (12 of 16 [75%]; Fisher exact test, 0.041; P < .05) or 15 to 20 years (6 of 7 [85%]; Fisher exact test, 0.047; P < .05). Similarly, veterinarians practicing for > 20 years reported wearing plastic face shields (9 of 47 [19%]) less than veterinarians practicing 1 to 5 years (7 of 14 [50%]; χ² = 5.306; P = .021).

Nearly all (124 of 128) veterinarians and technicians said that tularemia is transmissible from animals to people, with 4 veterinarians choosing not to answer. Fifty-five percent of respondents, including 64 of 109 veterinarians and 7 of 19 technicians, believed that tularemia is reportable when diagnosed in either an animal or human patient in Kansas, while only 13% (14 of 104) of veterinarians and 16% (3 of 19) of technicians answered correctly that tularemia is only reported when diagnosed in a human patient (Fisher exact test, 0.399; P > .05; Supplementary Material S3). Twenty veterinarians responded that they have reported veterinary cases of tularemia to the state or local health department.

Eight respondents, all veterinarians, reported having been diagnosed with or suspected to have tularemia themselves, with 7 responding that the suspected source was contact with a patient in their veterinary hospital also diagnosed with or suspected to have tularemia and 1 responding that the suspected source was contact with wildlife. These veterinarians came from diverse locations across the state (1 from Northwest, 1 from North Central, 2 from South Central, 2 from Northeast, and 2 from Southeast). Seven respondents reported that they have had a veterinary coworker diagnosed with or suspected to have tularemia, with 3 of these responding that the suspected source was contact with a patient in the veterinary hospital, 2 responding contact with wildlife, 1 responding unknown, and 1 not commenting on the source.

Respondents reported that, when they diagnose or suspect tularemia in a patient, nearly all (53 of 58 [91%] veterinarians, 5 of 6 technicians) discuss human health implications with pet owners. When asked whether they document these discussions in the pet’s medical record, 63% (35 of 56) responded always and 23% (13 of 56) responded most of the time, with only 9% (5 of 56) responding never. Three participants, from different veterinary clinics, responded that when they have seen cats or dogs with tularemia, they are aware that the pet’s owners have also developed clinical signs believed to be from tularemia, whether confirmed or not.

Discussion

This study’s findings support the occupational risk of tularemia to Kansas veterinarians, with 7% (8 of 109) responding that they have become infected and developed clinical signs of disease. While veterinarians are frequently listed (along with farmers, foresters, landscapers, and laboratory workers) as having occupational risk for tularemia, epidemiologic data with incidence among veterinarians per state have not been available.^8,17 Most (7 of 8) of these exposures were reported to be from patients, reinforcing the importance of awareness and personal protection within the practice setting. While the survey was anonymous and could not confirm these veterinarians’ diagnoses with laboratory tests or medical records, this provides motivation for further investigation into the true incidence among veterinary healthcare workers in Kansas and collection of data regarding route of transmission. Although the small number of sampled veterinary technicians did not self-report having had tularemia in this study, they should be considered at risk as well, in addition to veterinary assistants, as these veterinary personnel may all come into close contact with infected animals and their bodily tissues in the veterinary practice setting.

A report¹⁸ summarizing demographics of all Kansas residents with confirmed tularemia (N = 114) from 2012 to 2015 found that 59% (67 of 114) were exposed to a tick or biting fly, 40% (46 of 114) had lawnmowing or landscaping exposure, 15% (17 of 114) had exposure with a generally sick or dead animal outside the home, 13% (15 of 114) were exposed to a pet that was generally ill or died, and 12% (14 of 114) were exposed to a dead animal brought home by a pet, among other exposures. To better understand the One Health risk of tularemia transmission, future case investigations could include questions about veterinary and other occupational exposures and expand beyond reporting exposure to pets with general illness to specific questions about the animal’s health, the human-animal interactions, and proactively testing these animals for tularemia specifically when possible.

This study confirmed that Kansas veterinarians are diagnosing and treating clinical tularemia in pets, as nearly half (43% [47 of 109]) of responding Kansas veterinarians reported having diagnosed tularemia in a cat and 13% (14 of 109) in a dog. In cats, tularemia is most commonly associated with fever, lymphadenomegaly, anorexia, lethargy, oral ulceration, leukopenia and neutropenia, and potential hepatomegaly, splenomegaly, and pneumonia.^1,19 Tularemia was previously thought to be rare or mild in dogs, but a report²⁰ documented 88 dogs in New Mexico from 2014 to 2016 with clinical tularemia with moderate to severe illness and similar clinical signs as tularemia in cats. This emphasizes the importance of considering tularemia as a differential diagnosis for dogs with consistent exposure and fever, lethargy, anorexia, and lymphadenopathy as well as the need to examine, diagnose, and treat canine patients early rather than assume they will have mild self-resolving disease after exposure.

Inconsistent submission of laboratory testing to confirm disease in pets may hinder patient management and make it difficult to determine the risk of transmission to veterinary personnel and animal caretakers. While it is understandable that veterinarians face financial limitations and time constraints influencing their diagnostic decisions, other infectious and inflammatory differential diagnoses have overlap in clinical signs and organ involvement; thus, laboratory confirmation should be encouraged. Additionally, veterinarians have an ethical responsibility to promote public health, and failure to diagnose a zoonotic disease in an animal could be considered negligence breaching the professional duty of care.²¹ Veterinarians in this study reported using serology and PCR most often as diagnostic tools. While serology is generally the most cost-effective, antibodies might not form until 2 to 3 weeks after infection and false negatives can occur during acute infection. Thus, an initial negative antibody titer in the presence of clinical signs should prompt a follow-up titer. However, a single positive titer in the face of exposure and consistent clinical signs in an animal host may be sufficient for a diagnosis.^13,22 Similarly, though PCR is considered only supportive for human confirmation of disease, PCR is confirmatory for rabbits and rodents and can be useful for the detection of F tularensis from companion animals as well.^13,19,22 Submission of aspirates or tissue samples for culture and fluorescent antibody testing were also used by veterinarians in this study and can be helpful diagnostic tools, as can necropsies. Culture and necropsy should only be performed in diagnostic laboratories capable of additional biosafety precautions.¹⁵ No studies are available that compare sensitivity and specificity of available tests for tularemia in companion animals. Future development of cage-side diagnostic testing would be helpful to allow quick confirmation and rapid reporting and guide public health follow-up.

In human healthcare, doxycycline and other tetracyclines and streptomycin are the only FDA-approved treatments for tularemia.^23,24 However, in a retrospective analysis²⁵ of reported cases of tularemia from 2006 to 2021, tetracyclines, fluoroquinolones, and aminoglycosides were all associated with increased odds of survival when compared to patients treated with other antibiotic classes. Additionally, a recent study²⁶ found that all US F tularensis isolates tested (N = 278) were susceptible to doxycycline, tetracycline, ciprofloxacin, levofloxacin, gentamicin, and chloramphenicol. These same drug classes have been traditionally used in veterinary medicine and were the most commonly reported by veterinarians responding to this survey.^1,20,27 Clinical trials are needed to compare treatment outcome of antimicrobial agents for tularemia in cats and dogs as well as investigate optimal dosing protocols, including duration of therapy, to maximize efficacy and safety.

To minimize risk of zoonotic transmission in the veterinary clinic setting, correct and consistent use of PPE is essential. In a study⁸ of veterinarians exposed to tularemia from Wyoming, Oklahoma, North Dakota, and Minnesota, standard PPE was not used in 80% of veterinary exposures. Low-risk exposures include patient restraint, basic examinations, radiology, and noninvasive procedures, while high-risk exposures include fine-needle aspirates, lancing abscesses, lavaging wounds, and necropsies.⁸ When a necropsy is warranted for a tularemia suspect, the entire body should be submitted to an approved diagnostic laboratory.¹⁵ Historically, casual contact was not considered a route of transmission, but face snuggling and licking have now been implicated, with presumed transfer through saliva after the pet had an infected rabbit or rodent in their mouth; thus, it is recommended to avoid close contact with the face of tularemia suspects.¹⁶ The cage sign created in this study was designed to provide helpful guidelines for appropriate PPE for low- and high-risk exposures as well as response to exposures including self-monitoring and when to seek care from a healthcare provider (Supplementary Material S2).^8,15,16 In this study, veterinarians and veterinary technicians reported consistent glove use but were less consistent with other basic PPE (eye protection, face mask), especially during high-risk exposures. If an animal being handled is infected, this behavior could put them at risk for tularemia transmission. On the contrary, it was surprising that 15% (17 of 116) of survey respondents in Kansas reported using an N95 respirator for lancing abscesses or performing necropsies on tularemia suspect patients and 7% (8 of 121) reported using N95 respirators for basic care of tularemia suspects, as a 2008 study²⁸ found that only 6.7% to 8.5% of veterinarians reported having access to particulate filters such as N95s at work and fit testing of available respirators was rarely performed. N95 respirators require proper fit testing to form a tight seal around the mouth and nose and are designed to filter at least 95% of airborne particles as part of a respiratory protection program.^29,30 The increase in use seen in this survey might be due to increased familiarity and availability of these respirators after the COVID-19 pandemic. Educating staff, using cage-side zoonotic informational alerts, and creating a hospital infection control plan will fulfill ethical responsibilities to protect public health and minimize risk for veterinary personnel.^21,31

While this report verifies that Kansas veterinarians and technicians are knowledgeable about the zoonotic potential of tularemia and are educating clients about this risk and safety precautions, they are less knowledgeable about reporting requirements in the state. Over half (55% [71 of 128]) said it was reportable when diagnosed in humans or animals, when in reality tularemia is only reportable when diagnosed in a person in Kansas.^7,32 While some veterinarians do report veterinary cases to public health authorities, most do not. Given the known zoonotic potential of tularemia as well as 3 veterinarians in this survey reporting that their clients developed clinical tularemia, it is important that public health authorities are notified of cases of tularemia in pets so they can assist in communicating public health recommendations and follow-up. Further, as tularemia is considered a potential bioweapon, changing tularemia’s status to required reporting in animals could allow timely and appropriate public health response should case numbers rise during a bioterrorism event.

This study was limited by the small number of veterinarians responding overall and from the more rural regions in Kansas and the few veterinary technicians responding. Thus, these results might not represent beliefs and practices of all veterinarians and technicians who might treat cats and dogs in Kansas. On the basis of the Kansas population, we would expect most participants to be from Northeast (Kansas City) and South Central (Wichita) Kansas; however, we had the most participants from the North Central district. This may have been due to a disproportionate number of responses from Kansas State University, but our anonymous data collection prevented any further localization of participants. It is also possible that since we recruited from our continuing education population, more respondents came from communities nearest to our university. Further, comparisons of behaviors based on geographic location could not be performed because of these small numbers in some regions. Similarly, comparisons of behaviors between type of practice could not be performed because of the high proportion of small animal–exclusive and predominant veterinarians and technicians. Recall bias may have impacted the results, especially regarding the number of cases over time, and thus inferences about case trends from these data are limited. Additionally, more than 1 respondent may have participated from a single veterinary hospital, which might have impacted results, especially the number of tularemia cases cared for or diagnosed. Finally, response or courtesy bias, which is answering a survey the way you think you are supposed to but not necessarily truthfully, could have also occurred, especially for the PPE section, but this would not be expected to influence one population more than another.

In conclusion, veterinarians play an important One Health role in the recognition, diagnosis, and management of tularemia in cats and dogs and in the prevention of secondary transmission to veterinary personnel and pet owners. Though confirming tularemia diagnoses is a challenge for many veterinarians in Kansas, mainly due to financial limitations, testing should be prioritized to guide public health actions and recommendations regarding potential human exposures. Additional targeted educational efforts are needed for veterinary personnel regarding what PPE precautions are required for tularemia suspects, as well as when to report tularemia cases. Designating tularemia as reportable in animals would allow determination of disease trends and more rapid public health follow-up.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.