Seroprevalence and risk factors associated with Ehrlichia canis, Anaplasma spp., Borrelia burgdorferi sensu lato, and D. immitis in hunting dogs from southern Italy

Prevalence of Lyme Disease and Relapsing Fever Borrelia spp. in Vectors, Animals, and Humans within a One Health Approach in Mediterranean Countries

The genus Borrelia has been divided into Borreliella spp., which can cause Lyme Disease (LD), and Borrelia spp., which can cause Relapsing Fever (RF). The distribution of genus Borrelia has broadened due to factors such as climate change, alterations in land use, and enhanced human and animal mobility. Consequently, there is an increasing necessity for a One Health strategy to identify the key components in the Borrelia transmission cycle by monitoring the human-animal-environment interactions. The aim of this study is to summarize all accessible data to increase our understanding and provide a comprehensive overview of Borrelia distribution in the Mediterranean region. Databases including PubMed, Google Scholar, and Google were searched to determine the presence of Borreliella and Borrelia spp. in vectors, animals, and humans in countries around the Mediterranean Sea. A total of 3026 were identified and screened and after exclusion of papers that did not fulfill the including criteria, 429 were used. After examination of the available literature, it was revealed that various species associated with LD and RF are prevalent in vectors, animals, and humans in Mediterranean countries and should be monitored in order to effectively manage and prevent potential infections.

Detection of Anaplasma spp. and Ehrlichia spp. in dogs from a veterinary teaching hospital in Italy: a retrospective study 2012-2020

Anaplasma phagocytophilum, Anaplasma platys and Ehrlichia canis, responsible of diseases in dogs, are tick-borne pathogens with a proven or potential zoonotic role that have shown increasing prevalence worldwide. The aims of this retrospective study were to assess the frequency of Anaplasma spp. and Ehrlichia spp. exposure in dogs tested in a veterinary teaching hospital in Italy over a 9-year period, to compare the performance of the diagnostic tests used, to evaluate correlations with clinical data, and to genetically analyse the identified bacteria. During the study period, 1322 dogs tested by at least one of the rapid immunoenzymatic test, indirect immunofluorescent antibody test or end-point PCR assay for Anaplasmataceae detection were included. Dogs were tested if they had clinical signs or clinicopathological alteration or risk factors related to infection, and if they were potential blood-donor animals. Ninety-four of 1322 (7.1%) dogs tested positive for at least one pathogen: 53 (4.3%) for A. phagocytophilum, one (0.1%) for A. platys and 63 (4.6%) for E. canis. The number of dogs tested increased and the positivity rate progressively declined over the years. Comparison of tests showed a near-perfect agreement between serological tests and a poor agreement between PCR and indirect assays. A breed predisposition has been highlighted for A. phagocytophilum infection in hunting breed dogs and for E. canis infection in mixed breed dogs. Phylogeny confirmed potential zoonotic implications for A. phagocytophilum and showed no correlation of the identified bacteria with the geographical origin. Our study provides new insights into possible risk factors in dogs and evidenced discordant results between different tests, suggesting that a combination of serological and molecular assays is preferable for a correct diagnosis.

Effect of Breed on Hematological and Biochemical Parameters of Apparently Healthy Dogs Infected with Zoonotic Pathogens Endemic to the Mediterranean Basin

Dogs are considered the main reservoir of several zoonoses endemic to the Mediterranean Basin. In this study, a prevalence of infections and coinfections of canine vector-borne diseases was analyzed in apparently healthy dogs of different canine pure breeds in Sicily (Italy), where these diseases are endemic. The seroprevalence of Leishmania infantum, Ricketsia ricketsii, Anaplasma phagocytophilum, and Erlichia canis was assessed, as single and coinfections. Biochemical and hematological parameters were evaluated, and epidemiological factors, including sex, age, and canine breed, were recovered. The most frequent infection was L. infantum (45.61%), following R. ricketsii (36.84%), both as single, double, or triple coinfections. Coinfections change the biochemical and hematological parameters of the host, and canine breeds are related to the infection frequency and the parameters observed during infections. Changes in the complete blood count (CBC) and biochemical values also differ between canine breeds, with the Cirneco dell'Etna dogs infected with L. infantum being the animals presenting the most interesting results in our study. High values of RBC, hemoglobin, hematocrit, mean corpuscular hemoglobin (MCH), the albumin/globulin (A/G) ratio, and albumin and low levels of β-2 globulin and γ-globulin were found only in this canine breed, suggesting some resistance to infection in these dogs. Future studies about the immune response of this canine breed could be interesting to determine their possible resistance to zoonotic pathogens, such as L. infantum.

Emerging risk of Dirofilaria spp. infection in shelter dogs in southern Italy

In southern Italy, the number of autochthonous cases of Dirofilaria immitis in dogs has increased considerably. This also occurs in the Campania region, particularly in coastal areas, where infections with D. immitis and Dirofilaria repens have been reported more frequently. Therefore the aim of the present study was to better investigate the occurrence of Dirofilaria spp. in a local dog shelter in Castel Volturno (Campania region, southern Italy). Briefly, a total of 260 blood samples were analysed for identification of microfilariae (mff) and detection of Dirofilaria immitis antigen. Dogs were classified according to their age (1-3  years; 4-6  years; 7-11  years; > 11  years) and length of stay in the shelter at the time of sampling (dogs that entered in the shelter in the last 4  months; dogs housed in the shelter for more than 4 months up to 2  years; dogs housed for more than 2  years). The modified Knott's test revealed that 195 dogs (75.0%) were positive for circulating mff of Dirofilaria spp. Specifically, 104/260 (40.0%) dogs were positive for D. immitis and 91/260 (35.0%) were positive for D. repens. In addition, 72/260 (27.7%) dogs had both D. immitis and D. repens mff. Antigen testing revealed that 78/260 (30.0%) dogs were positive for D. immitis. However, 26/104 (25.0%) of the dogs with D. immitis mff were antigen-negative. The overall k concordance between the modified Knott's test and the antigenic test was ≤0.2 (poor) (p = 0.000). The results of the logistic regression model showed a significant association between Dirofilaria exposure and the period of time the dogs had spent in the shelter at the time of sampling. Dogs housed in the shelter for 4 months (group 1) and between 4 months and 2 years (group 2) had higher Dirofilaria positivity than dogs in group 3 (housed for more than 2 years) (80.4% vs. 79.6% vs. 62.4%, respectively). Moreover, male dogs and older dogs (between 7 and 11 years of age) were more likely to be infected with Dirofilaria spp.

Seroexposure to Zoonotic Anaplasma and Borrelia in Dogs and Horses That Are in Contact with Vulnerable People in Italy

Equine and canine anaplasmosis and borreliosis are major tick-borne zoonotic diseases caused by Anaplasma phagocytophilum and various species of Borrelia (the most important being Borrelia burgdorferi s.l.), respectively. This study evaluated the seroexposure to Anaplasma and Borrelia in dogs and horses used in Animal-Assisted Interventions or living in contact with children, elderly people or immunocompromised persons. A total of 150 horses and 150 dogs living in Italy were equally divided into clinically healthy animals and animals with at least one clinical sign compatible with borreliosis and/or anaplasmosis (present at clinical examination or reported in the medical history). Serum samples were tested with ELISA and immunoblot for the presence of antibodies against A. phagocytophilum and B. burgdorferi s.l., and the association between seropositivity and possible risk factors was analyzed using multivariate and univariate tests. Overall, 13 dogs (8.7%) and 19 horses (12.7%) were positive for at least one of the two pathogens. In addition, 1 dog (0.7%) and 12 horses (8%) were positive for antibodies against A. phagocytophilum, while 12 dogs (8.0%) and 10 horses (6.7%) had antibodies against B. burgdorferi s.l. Tick infestation in the medical history of the dogs was significantly associated with seropositivity to at least one pathogen (p = 0.027; OR 7.398). These results indicate that, in Italy, ticks infected with A. phagocytophilum and/or B. burgdorferi circulate in places where horses and dogs are in contact with people at risk of developing severe diseases. Awareness should be increased, and adequate control plans need to be developed to protect human and animal health, especially where vulnerable, at-risk individuals are concerned.

Co-infection patterns of vector-borne zoonotic pathogens in owned free-ranging dogs in central Chile

We investigated the co-occurrence of the nine of the most relevant canine vector-borne pathogens (CVBP) using conventional and real-time PCR and evaluated risk factors and potential non-apparent haematological alterations associated with co-infection in 111 rural, owned, free-ranging dogs in the Metropolitan Region of Chile.

At least one pathogen was detected in 75% of the dogs. DNA of Anaplasma platys (Ap; 36%), Candidatus Mycoplasma haematoparvum (CMhp; 31%), Mycoplasma haemocanis (Mhc; 28%), Trypanosoma cruzi (17%), Leishmania spp. (4.5%), and Acanthocheilonema reconditum (1%) was detected. All dogs were negative for Ehrlichia spp., Rickettsia spp., Bartonella spp., Piroplasmida, and Hepatozoon spp. Thirty-eight dogs (34%) were coinfected. CMhp was involved in 71%, Mhc in 58%, and Ap in 50% of the co-infections. The most common co-infection pattern was CMhp–Mhc (37% of the cases). The prevalence of Ap was higher in juvenile than in adult dogs, whereas the opposite was found for CMhp and Mhc. Adult dogs were four times more likely of being co-infected than juveniles. Co-infected animals showed higher white blood cell count, segmented neutrophil count, and GGT levels than non-co-infected dogs. Clinically healthy but infected dogs may act as reservoirs of CVBP, and their free-ranging behavior would facilitate the spread of these pathogens to other dogs as well as human beings or wild carnivores.

Distribution of Tick-Borne Pathogens in Domestic Animals and Their Ticks in the Countries of the Mediterranean Basin between 2000 and 2021: A Systematic Review

Tick-borne pathogens (TBPs) include a wide range of bacteria, parasites and viruses that cause a large spectrum of animal, human and zoonotic tick-borne diseases (TBDs). The object of this review was to establish an inventory and an analysis of TBPs found in domestic animals in the countries of the Mediterranean Basin. This geographic area occupies a central position between several continents and is an area of movement for animals, humans and pathogens of interest and their vectors, which is important in terms of animal and human health. In this systematic review, we included a total of 271 publications produced between 2000–2021 concerning TBPs in domestic animals. Among this literature, we found a total of 90 pathogen species (known as TBPs) reported in the 20 countries of the area; these were detected in tick species from domestic animals and were also directly detected in domestic animals. In all, 31 tick species were recorded and 12 domestic animal species, the latter comprising nine livestock and three pet species. More than 50% of the publications were from Western Europe. Island data were extracted and assessed, as islands of the Mediterranean Basin were represented in 16% of the publications and 77.8% of the TBPs reported. Our results show the importance of islands in the monitoring of TBPs, despite the low percentage of publications.

Simultaneous Exposure to Angiostrongylus vasorum and Vector-Borne Pathogens in Dogs from Italy

Several drivers have recently fostered the expansion of Angiostrongylus vasorum throughout Europe, where Vector-Borne Pathogens (VBPs) are also spreading. However, the level of simultaneous risk of infection is still unknown in canine populations. This study evaluated the simultaneous exposure to A. vasorum and major canine VBPs in dogs of Italy. Sera of 294 dogs were subjected to two ELISAs, detecting A. vasorum circulating antigens and antibodies against the parasite, and to the following assays: (i) SNAP® 4DX (IDEXX Laboratories Inc.) detecting Dirofilaria immitis antigens, and antibodies vs. Borrelia burgdorferi, Anaplasma spp. and Ehrlichia spp. and (ii) IFAT for the detection of antibodies vs. Leishmania infantum, Babesia canis and Rickettsia conorii. Twenty-two (7.5%, CI: 4.8-11.1%) and six (2%, CI: 0.7-4.4%) dogs scored positive for circulating A. vasorum antibodies and antigens, respectively. Seventeen dogs (5.8%, CI: 3.4-9.1%) were positive for A. vasorum antibodies + at least one VBP, three (1%, CI: 0.2-3%) for A. vasorum antigen + at least one VBP, while one dog (0.3%, CI: 0.01-1.88%) was positive for A. vasorum antigen + A. vasorum antibodies + B. canis antibodies. These results show that dogs living in different regions of Italy are at risk of simultaneous infections with both A. vasorum and VBPs. Despite the same scenario being likely in other countries of Europe, the current knowledge is scant. Therefore, further studies are warranted to amplify current epizootiological information and to understand whether control programs should be improved.

Seropositivity to canine tick-borne pathogens in a population of sick dogs in Italy

BACKGROUND

Canine vector-borne diseases (CVBDs) associated to ticks are among the most important health issues affecting dogs. In Italy, Ehrlichia canis, Anaplasma spp., Rickettsia conorii and Borrelia burgdorferi (s.l.) have been studied in both healthy canine populations and those clinically ill with suspected CVBDs. However, little information is currently available on the overall prevalence and distribution of these pathogens in the country. The aim of this study was to assess the prevalence and distribution of tick-borne pathogens (TBPs) in clinically suspect dogs from three Italian macro areas during a 15-year period (2006-2020).

METHODS

A large dataset (n = 21,992) of serological test results for selected TBPs in three macro areas in Italy was analysed using a Chi-square test to evaluate the associations between the categorical factors (i.e. macro area, region, year, sex and age) and a standard logistic regression model (significance set at P = 0.05). Serological data were presented as annual and cumulative prevalence, and distribution maps of cumulative positive cases for TBPs were generated.

RESULTS

Of the tested serum samples, 86.9% originated from northern (43.9%) and central (43%) Italy. The majority of the tests was requested for the diagnosis of E. canis (47%; n = 10,334), followed by Rickettsia spp. (35.1%; n = 7725), B. burgdorferi (s.l.) (11.6%; n = 2560) and Anaplasma spp. (6.2%; n = 1373). The highest serological exposure was recorded for B. burgdorferi (s.l.) (83.5%), followed by Rickettsia spp. (64.9%), Anaplasma spp. (39.8%) and E. canis (28.7%). The highest number of cumulative cases of Borrelia burgdorferi (s.l.) was recorded in samples from Tuscany, central Italy. Rickettsia spp. was more prevalent in the south and on the islands, particularly in dogs on Sicily older than 6 years, whereas Anaplasma spp. was more prevalent in the north and E. canis more prevalent in the south and on the islands.

CONCLUSIONS

The results of this study highlight the high seroprevalence and wide distribution of the four TBPs in dogs with clinically suspected CVBDs from the studied regions of Italy. The very high seroprevalence of B. burgdorferi (s.l.) exemplifies a limitation of this study, given the use of clinically suspect dogs and the possibility of cross-reactions when using serological tests. The present research provides updated and illustrative information on the seroprevalence and distribution of four key TBPs, and advocates for integrative control strategies for their prevention.

Haematological and biochemical abnormalities in hunting dogs infected with Acanthocheilonema reconditum, associated risk factors, and a European overview

Acanthocheilonema reconditum is a filarial parasite transmitted by arthropods (fleas, lice, and ticks) that infect dogs. There is minimal published data available to date on potential haematological and biochemical changes associated with this parasitic infection. Study aims were (i) provide an overview of A. reconditum in Europe, (ii) define A. reconditum prevalence and risk factors in a specific dog population (hunting) from southern Italy, and (iii) assess the frequency of haemato-biochemical abnormalities associated with infection. Blood samples collected from 3020 dogs were tested by a modified Knott's technique to count and identify microfilariae. Eighty-four dogs were infected by A. reconditum (2.78%; 95% CI 2.19-3.37%). Microfilariae ranged from 1 to 212/ml. Based on clinical examination, all but six dogs with non-specific symptoms were healthy. Haematological abnormalities included leucocytosis (n = 15), with eosinophilia (n = 14) and monocytosis (n = 13). Serum biochemical abnormalities included increased total serum proteins (n = 19), albumins (n = 7), total globulins (n = 14), ALT (n = 1), and ALP (n = 1); one dog was hypoalbuminemic, and BUN was mildly increased in 2 dogs. Risk factors included the province origin (Napoli, OR=5.4, 95%CI: 2.1-14.0; Caserta, OR=5.1, 95%CI: 2.5-10.6), hunting wild mammals (OR=2.8, 95% 95%CI: 1.6-4.8), and ectoparasite infestation (OR=1.9, 95%CI: 1.1-3.1). There was a negative correlation between microfilaraemic load and decreased albumin level (-0.37; p=0.021). Our results showed that A. reconditum circulates within the hunting dog population of southern Italy, with seemingly low pathogenic potential.

Exposure to Major Vector-Borne Diseases in Dogs Subjected to Different Preventative Regimens in Endemic Areas of Italy

Vector-borne diseases (VBDs) are globally widespread arthropod-transmitted diseases with a significant impact on animal and human health. Many drivers have recently spurred the geographic spread of VBDs in dogs. This study has evaluated the exposure to most important VBDs in dogs under different preventative treatments in different regions of Italy, i.e., Veneto, Friuli Venezia-Giulia, Umbria, Giglio Island (Tuscany), Abruzzo and Latium. Serological analyses were performed to detect antibodies against Leishmania infantum, Babesia canis, Anaplasma phagocytophilum/Anaplasma platys, Ehrlichia canis/Ehrlichia ewingii, Borrelia burgdorferi, Rickettsia conorii and the circulating antigen of Dirofilaria immitis. Dogs were categorized according to the treatment schedule usually received, and the association between seropositivity and possible risk factors was statistically evaluated. Overall, 124/242 (51.2%) dogs tested positive for at least one pathogen, while 34 (14.0%) were exposed to two or more pathogens. The most detected seropositivity was against R. conorii, followed by Anaplasma spp., L. infantum, B. canis, and the other pathogens under study. Significant statistical associations were found according to geographical provenance, history of tick infestation, lifestyle and inadequate prophylactic treatments. Random/irregular treatments have been identified as a clear risk factor. These results show that adequate prophylactic treatment protocols are overlooked by dog owners, despite the availability of several effective products, with possible implications in veterinary medicine and on public health.

Presence and Characterization of Zoonotic Bacterial Pathogens in Wild Boar Hunting Dogs (Canis lupus familiaris) in Tuscany (Italy)

Domestic dogs (Canis lupus familiaris) used for wild boar (Sus scrofa) hunting may represent incidental hosts for several zoonotic pathogens. This investigation aimed to evaluate the presence of anti-Leptospira antibodies and the occurrence, antimicrobial resistance, and virulence of Salmonella spp., Yersinia enterocolitica, and Listeria monocytogenes in sera and rectal swabs collected from 42 domestic hunting dogs in the Tuscany region (Italy). Regarding Leptospira, 31 out of 42 serum samples (73.8%) were positive and serogroup Pomona was the most detected (71.4%) at titers between 1:100 and 1:400. Four Salmonella isolates (9.52%) were obtained, all belonging to serotype Infantis; two of them showed antimicrobial resistance to streptomycin, while pipB and sopE presence was assessed in all but one isolate. Concerning Yersinia enterocolitica, seven isolates (16.7%) were obtained, six belonging to biotype 1 and one to biotype 4. Resistance to amoxicillin-clavulanic acid, cephalothin, and ampicillin was detected. Biotype 4 presented three of the virulence genes searched (ystA, ystB, inv), while isolates of biotype 1 showed only one gene. No Listeria monocytogenes was isolated from dog rectal swabs. The results suggest that hunting dogs are exposed to different bacterial zoonotic agents, potentially linked to their work activity, and highlight the possible health risks for humans.

Molecular survey on tick-borne pathogens and Leishmania infantum in red foxes (Vulpes vulpes) from southern Italy

Red foxes (Vulpes vulpes) have been recognised to harbour and transmit a wide range of tick-borne pathogens (TBPs) including those of zoonotic concern. To investigate the prevalence and the distribution of TBPs and of Leishmania infantum in foxes (n = 244), spleen samples were collected within the frame of a multi-regional wildlife health surveillance program in Italy. A combined PCR/sequencing approach was performed for the detection of Anaplasma spp., Babesia spp., Borrelia spp., Ehrlichia spp., Hepatozoon spp. and L. infantum DNA. Overall, 146 foxes (59.8 %, 95 % CI: 53.6-65.8) tested positive for at least one pathogen with Hepatozoon canis being the most prevalent (i.e., n = 124; 50.8 %, 95 % CI: 44.6-57.0), followed by Babesia vulpes (n = 20; 8.2 %, 95 % CI: 5.4-12.3), different spirochete species from Borrelia burgdorferi sensu lato complex (n = 9; 3.7 %, 95 % CI: 1.9-6.9), Ehrlichia canis and L. infantum (n = 7; 2.9 % each, 95 % CI: 1.4-5.8), Anaplasma platys (n = 4; 1.6 %, 95 % CI: 0.6-4.1), Anaplasma phagocytophilum ecotype I and Candidatus Neoehrlichia sp. (n = 3; 1.2 % each, 95 % CI: 0.4-3.5). All samples scored negative for Babesia canis and Borrelia miyamotoi. This study revealed the presence of spirochetes from B. burgdorferi s.l. complex, Ca. Neoehrlichia sp., A. platys and A. phagocytophilum ecotype I in red fox population from Italy, underling the necessity to monitoring these carnivores, mainly because they live in contact with dogs and humans. Data on the tick fauna circulating on wildlife species will complement information herein obtained, instrumentally to establish preventive strategies for minimizing the risk of infection for animals and humans.

Seroprevalence of Ehrlichia spp., Anaplasma spp., Borrelia burgdorferi sensu lato, and Dirofilaria immitis in Stray Dogs, from 2016 to 2019, in Southern Italy

Canine vector-borne diseases (CVBD) are an important and emerging health concern for humans and animals worldwide. The purpose of the presented study was to assess, from 2016 to 2019, the seroprevalence of CVBD agents and clarify the epidemiology of tick-borne disease in stray dogs living in the Campania Region, Southern Italy. For this purpose, blood samples were collected from January 2016 to December 2019 from 1023 dogs in authorized kennels located in the five municipalities of the Campania Region. SNAP^® 4DX^® from IDEXX^® Laboratories was used for detection of Ehrlichia spp., Anaplasma spp., Borrelia burgdorferi sensu lato (s.l.), and Dirofilaria immitis antibodies. The overall seroprevalence of CVBD in stray dogs was 19.6% (95% Confidence Intervals (CI): 17.2-22.8%; 201/1023). The most common pathogen was Ehrlichia spp., with a percentage of positivity of 16.03%, followed by Anaplasma spp. with 7.8%. B. burgdorferi s.l. and D. immitis were detected in only 0.2% of dogs; co-infection was detected in 4.5% of stray dogs tested. No link was detected between the gender, age, location, and CVBD seropositivity, except for Ehrlichia spp. for which location (Avellino Province; p = 0.007) and gender (male, p = 0.002) were risk factors for seropositivity. Our results demonstrated that animals are exposed to at least one of the four etiological agents (Ehrlichia spp., Anaplasma spp. Borrelia burgdorferi s.l., and Dirofilaria immitis) transmitted by vectors. Finally, this study highlighted the utility of serological monitoring in stray dogs, housed in kennels, given the threat posed by CVBD to animals and the zoonotic implications of these etiological agents and their vectors on human health.

Distribution and risk factors of canine haemotropic mycoplasmas in hunting dogs from southern Italy

Mycoplasma haemocanis (Mhc) and "Candidatus Mycoplasma haematoparvum" (CMhp) are the main haemoplasma species known to infect dogs. The aim of this study was to determine the prevalence of haemoplasma species infections in hunting dogs from southern Italy and assess related risk factors. 1,433 hunting dogs living in Campania region were tested by qPCR assay. The prevalence was 19.9 %; 13.1 % for Mhc and 11.4 % for CMhp; 4.6 % showed a coinfection with both haemoplasma species. Statistical analysis revealed living in Salerno province (Mhc: OR 3.72; CMhp: OR 2.74), hound (Mhc: OR 5.26; CMhp: OR 8.46) and mixed breed (Mhc: OR 3.38; CMhp: OR 2.80), rural environment (Mhc: OR 12.58; CMhp: OR 10.38), wild mammal hunting (Mhc: OR 8.73; CMhp: OR 8.32), cohabitation with other animals (Mhc: OR 2.82; CMhp: OR 2.78) and large pack size (Mhc: OR 2.96; CMhp: OR 1.61) as risk factors for haemoplasmas. Male gender (OR 1.44) and tick infestation history (OR 1.40) represented risk factors only for Mhc, while adult age (2-7 years - OR 2.01; > 7 years - OR 1.84) and large body size (OR 1.48) were associated only to CMhp. Mhc infection was significantly associated to Babesia vogeli (p < 0.05) and Hepatozoon canis (p < 0.001), while CMhp with H. canis (p < 0.001). This study adds information on haemoplasma species distribution in hunting dogs in southern Italy. Outdoor lifestyle and contact with wild fauna, through greater exposure to tick infestation, or possibly wounds acquired during hunting or fighting, could be factors contributing to haemoplasma infections.

Seroprevalence of Borrelia burgdorferi in Stray Dogs from Southern Italy

Borrelia burgdorferi is a bacterial pathogen transmitted by Ixodes ticks and is responsible for Lyme disease in both humans and dogs. The aim of this work was to evaluate B. burgdorferi diffusion among stray dogs in Palermo (Sicily, Italy) by serological methods in order to study the risk factors associated with the infection. Serum and blood samples of 316 dogs were collected from a shelter in Palermo, and were analyzed for the presence of antibodies against B. burgdorferi by indirect immunofluorescence assay (IFA), and of the ospA gene by real-time PCR, respectively. Seventeen sera (5.4%) were positive for the antibodies via IFA and one blood (0.3%) for ospA via real time PCR. On the basis of serological results, the evaluation of the potential risk factors (sex, age, breed and coat color) was carried out. The multivariate analysis indicated that male sex is a factor significantly associated with B. burgdorferi seropositivity. This study confirms that male dogs have a higher risk of developing the disease than females, and represents the first investigation on the spread of B. burgdorferi among stray dogs in Sicily.

Estimates for Lyme borreliosis infections based on models using sentinel canine and human seroprevalence data

Two models were developed to estimate Lyme borreliosis (LB) cases. One was based on the seroprevalence of Borrelia infections in human samples. This model used corrections for false negative and false positive results from published test sensitivity and specificity measures. A second model based on Borrelia infections in sentinel dogs was used to quantify the prevalence of Lyme disease Borrelia infections in humans; the reference baseline for this model was human and canine infections in Germany. A comparison of the two models is shown and differences discussed. The relationships between incidence, prevalence and total infection burden for LB were derived from published data and these were used in both models to calculate annual incidence, prevalence and total LB infections. The modelling was conservative and based on medical insurance records coded for erythema migrans. Linear model growth rates were used in place of the commonly adopted exponential growth. The mean of the two models was used to create estimates for various countries and continents. Examples from the analyses for LB estimated for 2018 include: incidence - USA 473,000/year, Germany 471,000/year, France 434,000/year and UK 132,000/year; prevalence - USA 2.4 million, Germany 2.4 million, France 2.2 million and UK 667,000; total infections - USA 10.1 million, Germany 10.0 million, France 9.3 million and UK 2.8 million. Estimates for the world for 2018 are: incidence 12.3 million/year; prevalence 62.1 million; and total infection burden 262.0 million. These figures are far higher than officially published data and reflect not only the underestimation of diagnosed cases, which is acknowledged by health agencies, but also undiagnosed and misdiagnosed cases.

Taenia hydatigena cysticercosis in wild boar (Sus scrofa) from southern Italy: an epidemiological and molecular survey

Taenia hydatigena cysticercosis is a widespread parasitic disease of wild and domestic animals. In Europe, the increase in wild boar population may potentially contribute to the spread of this parasitic infection. To determine the occurrence of cysticerci (metacestodes) in wild boar population from southern Italy, carcasses were inspected during three hunting seasons (2016-2018). Out of 3363 wild boar examined, 229 (6.8%) harboured cysticerci with 188 (82.1%) infected by a single cyst, vs 41 (17.9%) boars having more than one. Most of the positive animals (187; 81.7%) showed cysts on the liver, whereas a multiple localization of cysticerci was reported in 10 (4.4%) wild boar. The total number of cysts retrieved from positive animals was 301 (average 1.3). Molecular analysis revealed the occurrence of a common haplotype (Hap 8) shared between wild boar and domestic animals. Our findings suggest the presence of a T. hydatigena semi-domestic life cycle in which wild boar may play an important role, due to a large number of offal available to hunting dogs, wolves and foxes during hunting seasons. Hunters may be players in the management of wildlife species to control and prevent the circulation of parasitic diseases.

Hepatozoon canis in hunting dogs from Southern Italy: distribution and risk factors

Hepatozoon canis is a hemoprotozoan organism that infects domestic and wild carnivores throughout much of Europe. The parasite is mainly transmitted through the ingestion of infected ticks containing mature oocysts. The aims of the present survey were to determine the prevalence of H. canis in hunting dogs living in Southern Italy and to assess potential infection risk factors. DNA extracted from whole blood samples, collected from 1433 apparently healthy dogs living in the Napoli, Avellino, and Salerno provinces of Campania region (Southern Italy), was tested by a quantitative real-time polymerase chain reaction (qPCR) assay to amplify H. canis. Furthermore, the investigated dog population was also screened by qPCR for the presence of Ehrlichia canis, a major tick-borne pathogen in Southern Italy, in order to assess possible co-infections. Two hundred dogs were H. canis PCR-positive, resulting in an overall prevalence of 14.0% (CI 12.2–15.9). Breed category (P < 0.0001), hair coat length (P = 0.015), and province of residence (P < 0.0001) represented significant risk factors for H. canis infection. The presence of H. canis DNA was also significantly associated with E. canis PCR positivity (P < 0.0001). Hunting dogs in Campania region (Southern Italy) are frequently exposed to H. canis, and the infection is potentially associated with close contact with wildlife. Further studies are needed to assess the pathogenic potential of H. canis, as well as the epidemiological relationships between hunting dogs and wild animal populations sharing the same habitats in Southern Italy.

Hyperendemic Dirofilaria immitis infection in a sheltered dog population: an expanding threat in the Mediterranean region

A study on the occurrence of Dirofilaria immitis and its vectors was carried out in order to assess the prevalence of the disease in dogs in previously non-endemic areas of southern Italy. Blood samples (n = 385) and mosquitoes (n = 1540) were collected in two dog shelters and analysed by Knott's test and duplex real-time PCR, respectively. Dirofilaria immitis was the most prevalent filarioid (44.2%), while Culex pipiens was the most prevalent mosquito species (68.8%). This high prevalence of D. immitis infection confirms this location as one of the most hyperendemic foci of dirofilariosis in Europe.

Evaluación de enfermedades transmitidas por vectores en perros de un área de clima sub-frío de México

La distribución geográfica de las enfermedades transmitidas por vectores está influenciada por una dinámica compleja de factores ambientales, sociales y el impacto cambiante de la transmisión de sus vectores, huéspedes intermedios y reservorios. El objetivo del presente estudio fue evaluar la seropositividad a anticuerpos anti-Ehrlichia canis, Anaplasma phagocytophilum, Borrelia burgdorferia y la seropositividad a antígenos de Dirofilaria immitis en perros de un área de México con un clima semifrío. Se tomaron 100 muestras de sangre de caninos de hogares privados y en clínicas veterinarias del estado de Amecameca de Juárez, Estado de México. El análisis de las muestras se llevó a cabo mediante un kit comercial de ELISA (Test SNAP® 4Dx® Plus Canine IDEXX®). A los resultados se observó una seropositividad a anticuerpos anti-E. canis del 30 %, 9 % para A. phagocytophilum, 4 % para B. burgdorferi y 16 % para antígenos de D. immitis. Así mismo, se halló una relación estadísticamente significativa entre la seropositividad a anticuerpos anti-E. canis y perros mayores a un año y de raza. Por otra parte se reportaron resultados similares en perros machos y mayores de un año con seropositividad a D. immitis. Con los resultados obtenidos, se concluye que existe una mayor seropositividad para la infección por E. canis y D. immitis y una asociación significativa en perros mayores de un año. Es de gran relevancia conocer la epidemiología de patógenos transmitidos por garrapatas debido al impacto zoonotico que implican. Se recomiendan investigaciones adicionales, así como medidas preventivas de salud animal y salud pública para reducir el riesgo de infección en perros.

The global status of Dirofilaria immitis in dogs: a systematic review and meta-analysis based on published articles

Dirofilaria immitis is a parasitic filarial nematode responsible for heartworm disease in domestic as well as wild canines and felines and pulmonary or cutaneous infections in humans. This systematic review and meta-analysis aimed to evaluate the status of D. immitis in dogs based on available literature. Four English language databases (ISI Web of Science, Scopus, PubMed and Science Direct) containing data on D. immitis prevalence in dogs were thoroughly searched resulting in the inclusion of 193 studies. The findings revealed that the pooled and weighted prevalence of D. immitis infection in dog population based on published papers throughout the world was 10.91% (95% CI=10.18-11.65). In addition, subgroup analysis based on meta-regression revealed that a significant difference between the pooled and weighted prevalence of D. immitis in dogs and country (β =0.14, P=0.049). Given the relatively high prevalence of D. immitis infection in dogs and its adverse effects, it is suggested that to perform more research on the prevention and control of dirofilariasis infection in dogs worldwide.

Massive Taenia hydatigena Cysticercosis in a Wild Boar (Sus scrofa) from Italy

PURPOSE

Taenia hydatigena cysticercosis, due to Cysticercus tenuicollis, is a parasitic disease infecting domestic and wild animals worldwide causing economic and productive losses. Nonetheless, little attention has been paid to the role of the wild ungulates in the epidemiology of this disease. In the last years, the increasing population of wild boars in Europe has raised the attention of researchers on their role in the spreading of several infections, including those caused by cestodes. Herein, we report the description of a massive infection due to T. hydatigena cysticercosis in a wild boar from southern Italy.

METHODS

An adult female boar was examined during the hunting season 2018 within the regional project "Piano Emergenza Cinghiali in Campania". A complete necropsy was performed on the boar carcass and all viscera were examined to determine number and location of the cysts. Morphological and molecular analyses of the cysts were performed to confirm the C. tenuicollis identity.

RESULTS

The boar examined has revealed an impressive massive infection with 265 cysts. Measurements of the large and small larval hooks showed a mean of length as 200.3 µm and 136.8 µm, respectively. Molecular analysis of Cox1 and ND1 mitochondrial genes confirmed the C. tenuicollis identity.

CONCLUSIONS

Our findings suggest that wild boar could be involved in the epidemiology of T. hydatigena, due to the significant amount of boar raw offal available to definitive hosts (i.e., hunting dogs, foxes and wolves), during the hunting seasons.

Heartworm Disease (Dirofilaria immitis) in Two Roaming Dogs From the Urban Area of Castel Volturno, Southern Italy

The zoonotic filarioid nematode Dirofilaria immitis is transmitted by bloodsucking mosquitoes and causes heartworm disease in dogs and wild canines. In the last decade, D. immitis has spread in southern Europe including Italy. Few autochthonous foci of infection have been reported in previously non-endemic areas of southern Italy based only on the identification of microfilariae, antigen and serological tests, and polymerase chain reaction assay from both the blood of dogs and mosquito vectors with no description of cases of heartworm disease in both domestic and wild canines. Here, we report first on two cases of heartworm disease found at post-mortem examination in two roaming dogs from the urban area of Castel Volturno in Campania region of southern Italy. Immunological analyses of 11 roaming dogs from the same pack of those two submitted for necropsy and available necropsy data from the dogs recovered from the Campania region along the past 10 years were both negative for D. immitis infection. Although rare in southern Italy, these two cases are noteworthy because D. immitis may cause serious human infection. We highlight the need to identify the mosquito vectors of heartworm disease in this area using sensitive molecular assay for D. immitis DNA for predicting and controlling the spread of infection. We strongly recommend the control and systematic treatment of the domestic and roaming dogs that could constitute the most important infection reservoir.

Molecular Detection of Babesia spp. (Apicomplexa: Piroplasma) in Free-Ranging Canids and Mustelids From Southern Italy

Babesiosis is an emerging tick-borne disease caused by apicomplexan parasites with widespread geographical distribution and various wildlife species as reservoir hosts. The aims of this study were to investigate the prevalence and assess the role of free-ranging canids and mustelids in the maintenance of Babesia spp. in southern Italy. PCR analysis of splenic samples targeting the 18S rRNA gene revealed the presence of Babesia spp. in 36 of 82 (43.9%) red foxes (Vulpes vulpes) including 29 (58%) from Campania region and seven (21.8%) from Calabria region, in seven of 13 (53.8%) Eurasian badgers (Meles meles), and in one of 13 (7.7%) gray wolves (Canis lupus). Samples from other host species including 9 Eurasian otters (Lutra lutra), 1 stone marten (Martes foina), 1 least weasel (Mustela nivalis), and 1 European polecat (Mustela putorius) tested Babesia spp. negative. Sequence analysis of the 18S rRNA gene demonstrated the presence of B. vulpes in the red fox and two sequence types of badger-associated Babesia spp. in the Eurasian badger. The Babesia sp. sequence detected in the gray wolf was identical to a badger-associated Babesia sp. This study shows that the number of Babesia spp. infecting free-ranging carnivores in Italy is higher than currently believed, and suggests that these hosts may play an important role in the maintenance of the sylvatic cycle of these parasites. It is the first report of badger-associated Babesia spp. in Italy and in a gray wolf.

Cystic echinococcosis in wild boars (Sus scrofa) from southern Italy: Epidemiological survey and molecular characterization

Cystic Echinococcosis (CE) caused by Echinococcus granulosus sensu lato (s.l.) is one of the most important parasitic zoonotic diseases in the world and it represents an important public health and socio-economic concern. In the Mediterranean basin, CE is widespread and it is endemic in Italy, with major prevalence in southern areas. Several studies have investigated CE in domestic pigs, however, such data in wild boars are scant. In the last decades the wild boar population in Italy has increased and this ungulate could play an important role in the spreading of CE in the wild. Here we report on the prevalence and fertility rate of hydatid cysts in wild boars that were shot during two hunting seasons (2016-2017) in the Campania region of southern Italy. For each animal, a detailed inspection of the carcass and organs (lungs, liver and spleen) was performed and when cysts were found, their number, morphology and fertility were determined by visual and microscopic examination. Cysts were classified morphologically as fertile, sterile, caseous and calcified. Protoscoleces and germinal layers were collected from individual cysts and DNA was extracted to identify different strains/genotypes of E. granulosus s.l. Out of a total of 2108 wild boars 93 (4.4%) were found positive for CE. Infected animals were 45 males and 48 females, aged between 1 and 8 years. The average number of cysts per wild boar was 1.3 (min 1 - max 13). The total number of cysts collected was 123, of which 118 (95.9%) in the liver, 4 (3.3%) in the lungs and 1 (0.8%) in the spleen. Of all analyzed cysts, 70 (56.9%) were fertile and 53 (43.1%) sterile/acephalous. The presence of fertile cysts in 19.4% of CE-positive animals is noteworthy. Overall, molecular diagnosis showed 19 wild boars infected with the pig strain (G7).

Seroprevalence and risk factors associated with Ehrlichia canis in a hospital canine population

BACKGROUND

Ehrlichia canis (E canis) infection has been documented in a few small canine case series in Greece. However, there is limited information on the prevalence of exposure to, or the potential risk factors associated with E canis seroreactivity in a large native canine population.

OBJECTIVES

The objectives of this study were to evaluate E canis seroprevalence in dogs admitted to a veterinary teaching hospital, and to investigate the potential association between seropositivity and signalment, health status, the serologic assays used, and selected clinical and clinicopathologic abnormalities.

METHODS

The medical records of 850 client-owned dogs, tested using three in-office serologic assays, were retrospectively reviewed.

RESULTS

The E canis seroprevalence was significantly higher in sick (54.9%) compared with healthy (33.9%) dogs. Seropositivity differed significantly between the serologic assays used in this study (ImmunoComb vs SNAP 3Dx/SNAP 4Dx). Dogs presenting with bleeding tendencies, anemia, thrombocytopenia, leukopenia, pancytopenia, and hyperproteinemia were more likely to be E canis seropositive, and the median hematocrit (HCT), white blood cell (WBC), neutrophil, and platelet values were significantly lower in seropositive compared with seronegative dogs.

CONCLUSIONS

A high E canis seroprevalence was documented in a canine population living in an endemic area. Selected clinicopathologic variables might be useful indicators of E canis exposure and could allow the prioritization of serologic testing in the clinical setting.

Prevalence and risk factors for selected canine vector-borne diseases in Greece

Background

Canine vector-borne diseases (CVBDs) represent a wide group of diseases of major significance for canine health. In addition to their veterinary importance, many of these diseases are of great zoonotic concern, posing a risk of potential transmission to humans. To date, there has been scant knowledge regarding the prevalence, distribution and risk factors of CVBDs in Greece. Therefore, the objectives of the present study were to update the current knowledge on the seroprevalence of Dirofilaria immitis, Anaplasma spp., Ehrlichia spp. and Borrelia burgdorferi (sensu lato) in dogs in Greece and, furthermore, to assess possible environmental and any other risk factors associated with these infections. A total of 1000 apparently healthy and randomly selected dogs, presented in veterinary clinics, were involved at the national level (n = 66 municipalities). Serum samples were obtained from each individual dog and were tested using the SNAP^® 4Dx^® Plus kit from IDEXX Laboratories. Possible risk factors were assessed using binary regression models, including dogs’ lifestyle, climatological parameters and the altitude of the region.

Results

Overall, 21.8% (95% CI: 19.4–24.5%) of the sampled dogs were found to be seropositive to at least one of the four pathogens examined. The most prevalent pathogen was Ehrlichia spp. (12.5%, 95% CI: 10.6–14.7) followed by D. immitis (9.0%, 95% CI: 7.8–11.5) and Anaplasma spp. (6.2%, 95% CI: 4.9–7.9). The lowest prevalence (0.1%) was recorded for B. burgdorferi (s.l.) where only one dog was found to be positive. Among the examined risk factors, low mean temperature was found to increase the prevalence of Ehrlichia spp. (P ≤ 0.001) and Anaplasma spp. (P ≤ 0.001), while low minimum temperature increased the prevalence of D. immitis (P ≤ 0.001). In addition, low total annual rainfall had an effect of the prevalence of Ehrlichia spp. (P ≤ 0.01). Altitude also had a significant effect on the prevalence of D. immitis (P ≤ 0.05) and Anaplasma spp. (P ≤ 0.01).

Conclusions

To our knowledge, this is the first large-scale seroepidemiological study of CVBDs in Greece. It has been evidenced that environmental factors such as temperature, rainfall and altitude can influence the prevalence and distribution of CVBDs.

Endoparasites and vector-borne pathogens in dogs from Greek islands: Pathogen distribution and zoonotic implications

The present study investigated the presence of endo- and ecto-parasites, and vector-borne pathogens, in dogs from four islands of Greece. A total of 200 (123 owned and 77 sheltered) dogs were examined with different microscopic, serological and molecular methods.

Of the examined dogs, 130 (65%) were positive for one or more parasites and/or vector-borne pathogens. The most common zoonotic intestinal helminths recorded were Ancylostomatidae (12.5%) and Toxocara canis (3.5%). Ninety-three dogs (46.5%) seroreacted to Rickettsia conorii. Twenty-two (11%) of them were also PCR positive and 7 (3.5%) showed corpuscles suggestive of Rickettsia spp. on the blood smears. Nineteen dogs (9.5%) were seropositive for Ehrlichia canis, three of them being also PCR positive. Dogs positive for Anaplasma phagocytophilum-Anaplasma platys (1%), Dirofilaria immitis (0.5%) and Babesia canis (0.5%) were also found. Fleas and ticks were recorded in 53 (26.5%) and 50 (25%) dogs, respectively, and all specimens were identified as Ctenocephalides felis felis and Rhipicephalus sanguineus sensu lato. Binary multiple univariate Generalized Linear Models were used to investigate factors and clinical signs related to the recorded positivity, while the association of specific signs with the pathogens was evaluated using tests of independence. Knowledge of occurrence and impact of zoonotic parasites and vector-borne pathogens in dog populations is crucial to prevent the infection in animals and people, and to control the risk of spreading of these pathogens in endemic and non-endemic areas.

Both owned and sheltered dogs can harbor a variety of intestinal and extra-intestinal endoparasites, as well as vector-borne pathogens and ectoparasites, of zoonotic concern. Dog shelters and stray dogs are present in several touristic areas of Greece, including Sporades and Cyclades islands, where tourists often bring their pets with them, likely travelling from non-endemic to endemic areas. The present study has been carried out with the aim to evaluate the occurrence of the aforementioned pathogens. Data obtained showed that they are present in canine populations of Greece, with possibilities of infection for travelling dogs, which can also contribute to the spreading of zoonotic vector-borne diseases, introducing new pathogens in previously non-endemic areas. For these reasons, a constant monitoring of the epidemiological situation, improving control measures and correct diagnostic approaches are of primary importance for the prevention of canine and human infections, decreasing the spreading of potentially deadly pathogens.

Occurrence of canine and feline extra-intestinal nematodes in key endemic regions of Italy

Extra-intestinal nematodes of companion animals are of growing concern in veterinary medicine for their pathogenic potential and the current expansion throughout Europe. The present study has evaluated the occurrence of major canine and feline extra-intestinal nematodes in regions of Italy having epidemiological relevance. Associations of various recorded parameters related to the examined animals have been statistically evaluated, along with a comparative analysis with the most recent epidemiological data. Overall, 1055 dogs and 1000 cats were tested. Among extra-intestinal nematodes Angiostrongylus vasorum was the most common in dogs followed by Capillaria aerophila and Dirofilaria spp.; Aelurostrongylus abstrusus was the most recorded parasite in cats, followed by C. aerophila and Troglostrongylus brevior. The statistical analysis revealed that outdoor access is associated with A. vasorum, A. abstrusus and T. brevior infections, that were also more prevalent in animals with cardio-respiratory signs. Moreover, cats aged less than 12 months had more chances to be infected by lungworms. The data herein presented confirm the occurrence and the possible risk of expansion of different extra-intestinal parasitoses of dogs and cats in Italy, underlining the importance of a constant epidemiologic vigilance and of appropriate control methods.

Serological Survey of Ehrlichia canis and Anaplasma phagocytophilum in Dogs from Central Italy: An Update (2013⁻2017)

Ehrlichia canis and Anaplasma phagocytophilum are tick-borne bacteria of veterinary concern. Indirect immunofluorescent assay was carried out to detect antibodies against E. canis and A. phagocytophilum in 1026 owned dogs living in Central Italy during the period 2013–2017. One hundred and eighty-six (18.12%) dogs were positive for at least one pathogen and 14 (1.36%) for both agents. More in detail, 166 (16.18%) samples were positive for E. canis and 34 (3.31%) for A. phagocytophilum. No statistically significant differences in the seroprevalence values related to gender were detected, whereas the highest rate to E. canis occurred in animals aged more than 10 years. Mean seroprevalence values for both E. canis and A. phagocytophilum detected in 2014 and 2015 were statistically higher with respect to other years. Even though dogs’ owners are informed about the risk of pet infections by tick-borne pathogens and prophylaxis against ticks is often executed, E. canis and A. phagocytophilum are still present and infect the canine population in Central Italy.

Seroprevalence of vector-borne pathogens in dogs from Croatia

Canine vector-borne pathogens (VBPs) are a group of globally distributed and rapidly spreading microorganisms transmitted by arthropods. In the present survey, we investigated Anaplasma spp., Ehrlichia canis, Dirofilaria immitis and Borrelia burgdorferi sensu lato seroprevalence between three groups of dogs (asymptomatic, suspected and deceased) from continental and coastal regions of Croatia with the commercial point-of-care SNAP®4Dx®Plus for VBPs. The overall prevalence for tested pathogens in dogs was 6.1% with the highest prevalence detected for Anaplasma spp. (4.5%), while the remaining pathogens were found at a prevalence of less than 1% (E. canis 0.6%, B. burgdorferi s.l. 0.4%, D. immitis 0.6%). No statistically significant differences in VBP detection between dog cohorts could be found with the exception of D. immitis in the deceased group. Interestingly, no evidence of D. immitis could be found in the hearts of dogs in this group at necropsy, however. This study provides the first data on the seroprevalence of selected VBPs between dogs of different health statuses in Croatia. The results demonstrate that serological evidence of VBPs alone or in combination with co-infections were found just as frequently in asymptomatic dogs as those with suspected or confirmed evidence of VBP disease, raising questions about the pathogenic potential of these organisms in domesticated dogs.

Control of Lyme borreliosis and other Ixodes ricinus-borne diseases

Lyme borreliosis (LB) and other Ixodes ricinus-borne diseases (TBDs) are diseases that emerge from interactions of humans and domestic animals with infected ticks in nature. Nature, environmental and health policies at (inter)national and local levels affect the risk, disease burden and costs of TBDs. Knowledge on ticks, their pathogens and the diseases they cause have been increasing, and resulted in the discovery of a diversity of control options, which often are not highly effective on their own. Control strategies involving concerted actions from human and animal health sectors as well as from nature managers have not been formulated, let alone implemented. Control of TBDs asks for a “health in all policies” approach, both at the (inter)national level, but also at local levels. For example, wildlife protection and creating urban green spaces are important for animal and human well-being, but may increase the risk of TBDs. In contrast, culling or fencing out deer decreases the risk for TBDs under specific conditions, but may have adverse effects on biodiversity or may be societally unacceptable. Therefore, in the end, nature and health workers together must carry out tailor-made control options for the control of TBDs for humans and animals, with minimal effects on the environment. In that regard, multidisciplinary approaches in environmental, but also medical settings are needed. To facilitate this, communication and collaboration between experts from different fields, which may include patient representatives, should be promoted.