CDC ZOHU Call May 6, 2026

Hi, everyone. Thanks for joining. We'll begin in a moment. I'm going to wait a few more seconds as people join, and then we'll begin. Good afternoon. I'm Keisha Bohannon, and I work in CDC's One Health Office in the National Center for Emerging and Zoonotic Infectious Diseases at the Centers for Disease Control and Prevention. On behalf of our office, welcome to our May Zoonoses and One Health Updates call. Next slide, please. This webinar is designed for veterinarians, physicians, epidemiologists, and other public and animal health professionals in federal, state, and local positions, but all are welcome. Today's webinar will be recorded. If you'd rather not be included, feel free to disconnect. Links to resources from each presentation are available on our website at cdc.gov slash ZOHU dash call slash webinars dash may dash 26 dot html. Next slide. Today's presentation will address one or more of the following five objectives. One, identify an implication for human, animal, and environmental health. Two, identify a One Health approach strategy for prevention of public health threats. Three, identify a One Health approach strategy for detection of public health threats. Four, identify a One Health approach strategy for responding to public health threats. And five, list two ways to improve collaborative practice across the public health care team. Next slide. In compliance with continuing education requirements, all planners and presenters must disclose all financial relationships in any amount with ineligible companies over the previous 24 months, as well as any use of unlabeled products or products under investigational use. CDC, our planners and presenters, wish to disclose they have no financial relationships with ineligible companies whose primary business is producing, marketing, selling, reselling, or distributing health care products used by or on patients. Content will not include any discussion of the unlabeled use of a product or a product under investigational use, and CDC did not accept commercial or in-kind support for this activity. Next slide, please. Instructions for receiving free continuing education are available at cdc.gov slash sohu-call slash about slash ce.html. To receive free CE for today's webcast, sign in or create an account at train.org by June 8, 2026. The registration code for this course on CDC TRAIN is sohuwebcast. A captioned video of today's webinar will be posted on our May call page within 30 days. Free continuing education for the web-on-demand video of today's webinar will be available until June 9, 2028. Next slide, please. Before we begin today's presentation, CDC's One Health Office Director, Kasey Barton Behravesh, will share some news and updates. Good afternoon. Hi, everyone. Thank you for joining the May ZOHU Call. We want to share a few updates with everyone and let you know that you can find the links to them in today's ZOHU Call email newsletter. If you're not subscribed to the newsletter, you can quickly sign up using the link on our main ZOHU Call webpage. So, moving forward, you can get this information. CDC is working closely with the U.S. Department of Agriculture, the Department of the Interior, and many other governmental and non-governmental partners to respond to an outbreak of New World Screwworm. Right now, it's in Central America and Mexico, but this pest can impact livestock, companion animals, wildlife, and people. There are no cases in the United States as of today. You can find the latest updates on USDA and CDC's website and on the whole of government website screwworm.gov. Next slide. In today's newsletter, we highlight several recent publications, including a publication highlighting severe illness associated with eating mushroom-containing chocolate products, a publication detailing the emergence of extensively drug-resistant shigellosis, and one on highlighting geographically distinct circulation of genotype 2 and 3 St. Louis encephalitis virus. And finally, we share a publication highlighting the evaluation of effectiveness of autocidal gravid overtraps for preventing Zika virus infection. Next slide. The newsletter also highlights recent announcements and resources, including a USDA Ask the Expert interview on growing conservation solutions. Next slide. And we wanted to share a few events and observances to highlight for the month of May, including that May is Lyme Disease Awareness Month. This week, May 3rd through the 9th, is National Pet Week. May 15th is Endangered Species Day, and there are many more animal and wildlife observances shown on the slide and will be linked to in our newsletter. Next slide. Finally, we wanted to update you on some active outbreaks, and we've shared a link for a salmonella outbreak investigation link to backyard poultry with tips on staying safe if you have backyard chickens or other poultry. You can visit CDC's Healthy Pets, Healthy People website for a selected list of ongoing and past U.S. outbreaks of zoonotic diseases, and also details about additional ongoing U.S. outbreaks. All will be in today's newsletter. We invite you to continue sending presenter and topic suggestions for future presentations, as well as news from your organization that you'd like for us to share to ZOHUCALL at CDC.gov or Z-O-H-U-C-A-L-L at CDC.gov. We encourage you to share the ZOHUCALL website link with your colleagues from many different sectors, public health, agriculture, wildlife, plant, environment, and others, so we can let them know about the live and recorded webinars and free continuing education that the ZOHUCALL offers. Next slide, and back over to you, Keisha. Thanks, Casey. You may submit questions at any time using Teams Q&A feature. Please include the topic or presenter's name. The Q&A session will follow the final presentation if time permits, and you may also email questions to today's presenters. We've included their email addresses on this slide and in the email newsletter sent today. Next slide, please. Our first presentation, an Operational Risk Assessment Tool for Evaluating Leishmania Infantum Introduction and Establishment in the U.S. through Dog Importation, will be shared by Dr. Christine Peterson and Dr. Anne Straley. Please begin when you're ready. Thanks so much for that, Keisha, and thanks for inviting us to join you for this ZOHUCALL. My name is Dr. Christine Peterson, and I will kind of give the background on Leishmaniasis, and then I'll be handing it over to Anne. I wanted to give a shout out to Dr. David Marquez, who also helped us get this tool together, but because of his schedule, could not join us today. Next slide, please. I do not, nor does Anne, have any conflicts with this, and we will not mention anything relating to a Next slide, please. So, for those of you who did not have the pleasure of the probably hour-long lecture you got as a veterinarian student, this is the life cycle of Leishmania. This is particularly the life cycle of Leishmania Infantum. Leishmania is an obligate intercellular protozoan parasite, and what that means is it lives inside cells, as you see in the pictures here, particularly phagocytic cells like macrophages and monocytes. Dogs are the primary reservoir species of Leishmania Infantum, and in the little picture, you see a kind of fuzzy small fly. This is a sand fly, as it says at the bottom, and they take blood meals from dogs or people, and that's how the disease is spread in tropical areas of the world. It's also known that there can be other routes of transmission, and we will talk about that a little bit. Sand flies are of the genus Lutsamia and Phlebotomus, and they're a biological vector. So, what this means is the parasite has to go into the sand fly to have meiosis or parasite sex in order to get diversity of their genome. So, if they do not do that, they reproduce clonally, and that's what happens within macrophages. Next slide, please. Visceral leishmaniasis is found all over the globe. You see that in the dark color are the countries that have had the most cases. It's found in roughly 88 to 89 countries globally, and there's about 20,000 deaths, human deaths, globally each year, making leishmania the second most dangerous parasite in the world compared to malaria as the first. Likely, there's probably millions of dogs that die of this disease each year or are euthanized because of signs of the disease or as a public health measure. There are still countries that use culling as a way to control this disease. Dogs were recently shown to be a potential reservoir of leishmania donabani in India that actually came out in the same time this tool came out in EID back in the fall of 2024. With elimination efforts in the sub-Indian continent, cases have really dramatically dropped there, so the predominance of cases now happen in eastern Africa, with still a bunch of cases happening within Brazil, throughout the Mediterranean basin, and you'll hear about why we're worried about it in the United States today. Next slide, please. This map talks about where we've seen human, canine, and feline cases, and that's what's in dark blue. Human cases are in the light blue, and a lot of those, especially the one up in North Dakota, was a travel case. There was an equine case of leishmania mundii in Florida a couple years back in the kind of light or seafoam green. That's where we know there's sandflies because of reports or it could happen, and then there's a bunch of states where we don't know, and those are kind of in the hashed gray. So overall, we are aware that we've got endemic cutaneous leishmaniasis caused by leishmania mexicana in Oklahoma and Texas. There, the vector is likely to be leucamia anthrophora. There's possibilities that it could be diabolica, which has a much more fun name, so I vote diabolica, and there the wood rat is the reservoir. As you see, sandflies are really found throughout half the southern half of the United States, and we do know that leucamia shenoni has been shown to have both the capacity and the capacitance to be a vector species for leishmania infantum, so that's something that we're always watching as a potential cause for spread of leishmania, but thankfully, there has not yet been active vector spread of leishmania in the United States. Next slide, please. Leishmania is, of course, a global problem, and cases have been reported to be spread congenitally all over the globe where we have cases of this disease. Interestingly, we also get reports of congenital or vertical transmission of leishmaniasis in non-endemic countries, so places where humans are not acquiring this disease, likely from the sandfly, so that's shown in these dark squares up in northern Europe. It's been shown throughout the United States in dogs, and then, of course, we've had cases in endemic areas also globally. Shout out to Tara Greenish Pulley and Scott Davis for putting out this work for us. Next slide, please. So that, of course, begs the question. A lot of you might have heard that in the United States, we have canine leishmaniasis in hunting hounds. We do, absolutely, and that's the cohort that I've learned a lot about vertical transmission, particularly transplacental transmission of this disease in dogs, but also in other species. So we've been asked many times, how did this start, and where did it come from? So I'm going to take a couple slides to talk about that. I think this might be a slide where you can click once, and we'll get a little—yep. So this is just showing another version of the life cycle and reminding you of things that I kind of went over in that first life cycle, but if leishmania is not going into the sandfly, it's going to reproduce clonally, and that means that it doesn't change much, except for major crossover events during mitosis, but otherwise, we have reproduction through meiosis, and that's what happens in the sandfly. So there are ways that this actually could be used, aside from just being nerdy and saying those words, to use it as a diagnostic test to tell if a transmission was vertical versus vector-borne. Not something we've really gone forward with yet, but it is something to think about for the future. Next slide, please. So in order to answer where this came from, we took blood samples from seven dogs across four large kennels in the United States, hunting hound kennels. All of these within two generations represent more than 12 kennels from nine states in the United States, and it probably then represents leishmania and phantom genetics from both the Midwest and the Eastern United States. Parasites from these blood samples were cultured before we then submitted them for DNA extraction and whole genome sequencing. Next slide, please. Through that sequencing and working with a postdoc, Suzanne Franson, and James Cotton, a PI who was at the time at the Sanger Institute in Cambridge, England, we were able to perform a phylogenetic tree, which is shown here in this picture. And what we found, if you look at kind of the light blue in the top, just down from the four French samples that are kind of that very bright blue, is FOXIMO. And that is the strain of leishmania that's been found in the United States. There are the seven samples that we used for this. And if you look back up this phylogenetic tree, you see that the U.S. samples are clading directly off of those French samples, as well as the next closest one is an Italian sample. So what this tells us is that this was not of South American origin, which is all of that green down below. It's further distant from that, and it's much more closely related to these European samples, indicating that the geographic origin was likely from Europe. Next slide, please. Ah, thank you. That's the U.S. So as I was telling you, this can be looked at through further genetic analyses using both a native rejoining tree and a maximum likelihood tree. It looks like these samples clade separately, but either more closely with France or potentially, you know, more distant, but with these Italian samples, again, indicating that we think that it was the south of Europe where these came from. And if you hang out with people that hunt foxhounds, which I have done, you will learn that in England, if you want a faster foxhound, you're going to go to France where they hunt deer. And of course, the south of France is endemic for Leishmania and phantom. So that's how we think this happened. Next slide, please. Next slide. Oh, there we go. And I think I'm over to Anne now. Thanks, Dr. Peterson for that great background. And so we know that globalization will increase the risk of disease introduction into new areas, and this can happen for dogs through international pet travel, pet importation, either through rescue organizations or breeders. But there is, as Dr. Peterson mentioned, around a 15% prevalence of L-infant among dogs worldwide. So the risk of importation and spreading this thing with dogs, you know, is not zero. Next slide, please. So we set out to develop a tool to enable folks to answer this question of, is this imported dog a risk? And if it is, what do I do? So I used to work at CDC's parasitics disease branch, and we would get this question not all that infrequently on our parasitic disease hotline. So this operational risk assessment tool, which I'll refer to as the ORAT for short, is a qualitative risk assessment tool. And it was developed by an interdisciplinary working group of people, including Dr. Peterson and myself, with backgrounds in veterinary epidemiology, infectious diseases, leishmaniosis, public health, vector ecology, and nervous sciences. And we used established risk assessment frameworks. The output of this tool, you know, the information that you get from applying it is intended to help animal health and public health officials identify and manage risk associated with importing a dog infected with L-infant. It was published in the journal Emerging Infectious Diseases, which is open access in December of 2024. And I'm going to provide an overview of the tool, and then we will work through a case study to apply it. Next slide, please. So first, the general overdue methodology of the risk assessment process. The first step is to identify the hazard and any key assumptions that need to be made in order to characterize that hazard and the risks that it will occur. Next, we identify the steps necessary for the hazard to occur and assign a probability to each step as a qualitative risk category, because you know this is a qualitative tool. And so our qualitative risk categories are very low, moderate, and high. Finally, the consequence of the hazard occurring is assessed, and a final risk is determined on the basis of the overall probability. At each phase, we consider the currently available evidence as well as the uncertainty of that evidence. So the assumptions that we made were that imported dogs are representative of the general US population, and they are equally susceptible and equally infectious to sandflies, so they're not considered super spreaders or anything. The second assumption that we made about the hazard for the purposes of the risk assessment was to, was that US sandflies, particularly that species Lutemia shinoni that Dr. Peterson mentioned, could act as a permissive vector for L. infantom, and we'll talk more about that in a minute. And third, we assumed that sandfly preventatives applied topically to dogs are effective at reducing sandfly feeding and survival. Next slide, please. So the ORAT occurs in or is used in three parts, and the first of these is the entry assessment, and this describes the pathways needed to import an infected dog to introduce L. infantom to the US and estimates the probability of that process occurring. Next slide, please. With the entry assessment, there's a few key factors that must be considered, including the dog's country of origin and that country's endemicity status for L. infantom, and Dr. Tarrant will talk more about this in the next presentation. The next factors that must be considered are the amount of time spent in an endemic area, and previous studies have indicated that dogs that are traveling to an endemic area for less than three weeks are at a low risk of infection, particularly if they are treated with sandfly preventatives, which is the next factor to consider. Also important is the dog's clinical status, whether they're symptomatic for leishmaniasis, any clinical pathologic abnormalities, their serologic status. A dog's lifestyle or occupation, for example, whether they are a stray, a working animal, or a family pet, influences the amount of time that they spend outside and are exposed to sandflies, and so there's another important consideration, as well as whether the animal was born to a dam that was infected with L. infantom. As we know, as Dr. Peterson mentioned, that the infection can be passed vertically. Now you'll notice the little green box in the upper right-hand corner. If you remember back to the methodology slide, for each stage of the risk assessment, in addition to reviewing the available evidence to inform each step, we also considered the uncertainty level of that evidence. So for the entry assessment and each of the factors that informs the probability here, the uncertainty level is considered low, and what this means is that there were sufficient studies available to inform this step of the assessment, and there Next slide, please. So next is the exposure assessment, which describes the biologic pathway necessary for the release of L. infantom from an imported dog, and subsequent exposure of humans and other animals in the U.S., and the likelihood of that occurring. For the exposure assessment, we considered whether permissible vector sandfly species were present in the U.S., and where they would be, along with weather conditions that affect their vector competence. So we're going to pause here for a minute and unpack this a little bit more. A competent vector is one that is susceptible to infection with L. infantom and is capable of transmitting it to other hosts, and not all sandfly species are competent vectors, but some may be considered permissive vectors, which means they can support the development of the parasite, but not transmit it further. Now, there are a few studies that have assessed infection rates of L. infantom in sandflies, but there are experimental studies, like Dr. Peterson mentioned, that have shown that Lutamia chinensis sandflies can feed on infected hamsters and dogs and support parasite development, so they are considered a permissive vector. So for the purposes of this ORAT, we assume that Lutamia chinensis sandflies are permissive vectors. These sandflies are widely dispersed across the United States. In the map on this slide, states where Lutamia chinensis sandflies have been recorded are outlined in the black and white dashed line, and within its range, the sandfly occurrence and abundance is subject to local environmental factors like precipitation, temperature, habitat availability, the presence of suitable hosts, so it's not a blanket distribution within those states. In general, sandflies develop, feed, and thrive at a temperature range somewhere between 20 and 28 degrees Celsius, but 17 degrees Celsius is considered the minimum sandfly survival temperature. So the colors on this map indicate where the average minimum temperatures during peak sandfly season in July would be sufficient to support sandfly occurrence in order to conservatively predict areas that might be at higher risk for vector-borne transmission due to Lutamia chinensis, and those are the red areas. Now keep in mind that this map does not take into account those other factors that are important like humidity, wind, precipitation, habitat availability, or the presence of suitable hosts. Additional factors that can affect the probability that a dog will be exposed to sandflies and potentially transmit their infection to that sandfly include whether the dog is on appropriate sandfly preventives, whether the dog is currently being treated for leishmaniasis, and the dog's occupation and exposure to the outdoors. So now let's look at the little red box at the bottom of the slide. The uncertainty level of the available evidence for this step in the assessment is high because there's a lot of variability in the available evidence, and chief among these are the uncertainties of whether domestic Lutamia chinensis flies are actually capable of transmitting Allantantin from one animal to another. As Dr. Peterson pointed out, Allantantin is present in hunting hounds in the U.S. and has been for many years, but studies have demonstrated that transmission of infection occurs primarily through vertical transmission. As she stated, to date we haven't seen evidence of electronin spread. When it comes to treatment status, we know that treatment of dogs with Allantantin infection rarely results in complete clearance of the parasite, but it does reduce their parasite burden and therefore their infectiousness to sandflies. But not all drugs substantially reduce parasitic loads, and there are reports of resistance to commonly used drugs in some areas. And while studies have generally identified a positive association between the severity of a dog's infection and their infectiousness to sandflies, the clinical scores used to define severity were highly variable, making comparison across studies challenging. So now we've come to the consequence assessment, which considers the consequences of further establishment of Allantantin in the general population and its impact on human and dog health. Next slide, please. Consequences if Allantantin becomes established in the U.S. may be biological in nature, but can also include economical as well as environmental impacts. Health consequences for individuals will vary based on their immune status and response to treatment. Studies suggest that up to 25% of exposed dogs in endemic areas that can mount an effective immune response might clear their infections without treatment. But generally, immunocompromised dogs and humans are at the greatest risk for adverse outcomes due to an Allantantin infection. There are also broader public health impacts to consider. If Allantantin were to become established and spread via vector-borne transmission to humans and other dogs, would control programs become necessary to combat the spread like those that exist for West Nile virus, for example? And although it's rare, there is also a risk of iatrogenic transmission of infection from dogs to humans through events like needle sticks, and that should be considered as well. The uncertainty level in this step is low as there were sufficient studies to characterize the potential consequences, but I do want to point out that it was beyond the scope of this project to perform a quantitative analysis of the potential economic and environmental consequences. Next slide, please. So now we come to the final risk estimation matrix. This matrix combines the probabilities of importation and vector-borne transmission with the outputs of the consequence assessment, enabling the risk assessor to evaluate the overall risk for importation and establishment of Allantantin. And once the overall risk is determined, then appropriate risk mitigation strategies can be devised. Next slide, please. Okay, so this might all seem a little abstract still, so I thought that we would walk through a little case study and apply the tool. So as this tool is intended to provide animal health and public health professionals with a strategy to assess risk and develop risk mitigation strategies, let's pretend for the moment that that's your role, and you've been alerted to an imported dog that might pose a risk-relational nexus. So the subject of our case study is Daisy. Daisy is a completely fictitious five-year-old intact female French bulldog who was made up for the purposes of this presentation. Some things to know about Daisy as we walk through her case, she was purchased from a breeder in Spain and was moving to the U.S., specifically the state of Georgia, and she is intended to be used as a breeding animal, and her owner is immunocompromised. Next slide, please. So step one is to determine the probability of importing an infected dog. Next slide. So let's say you have access to Daisy's medical record, and upon review you know that she doesn't currently have any suspicious skin lesions, but she did have a mass biopsy in 2023 that identified Leishmania parasites, and her quantitative serology is positive. When asked, the owner reports that she doesn't think Daisy has been on preventives while living in Spain. Next slide, please. So here I would say that the probability of importing an infected dog is high. We have documented evidence that Daisy has been infected with Leishmania, and we will learn from Dr. Tarrant's presentation in a minute that Spain is an endemic country for phantoms, and furthermore, Daisy has not been maintained on sample by preventives while in Spain. Next slide, please. So next we consider the probability of vector-borne transmission after Daisy moves to the U.S. If you click one more time. So here we would consider the probability to be moderate. Daisy will be moving to Georgia, which has a documented presence of a permissive vector, as well as a temperature range that supports its presence. For more detail on how we arrived at this designation of moderate as opposed to high or low, which unfortunately I don't have time to cover in this presentation, I encourage everyone to read the full article where this is further explained in the appendix. Next slide, please. So next we determine the combined probability of events. If you click one more time. So let's go across the top of the table first, which is the probability of importing an infected dog. And for Daisy, this was considered high. So now we're looking at the last column on the table on the top right-hand side. So next, we're going to go down the left side of the table, which is the probability of vector-borne transmission, which we said would be moderate. And so now we look to see where those two things intersect on the table. And the resulting combined probability of events here is considered to be moderate. Next slide, please. So next, we determine the impact on individual canine and human health. Next slide. So here I chose to highlight a few things, but in practice, there may be additional considerations that you might make. The probability of vertical or horizontal transmission is high in this case because Daisy is intended to be used as a breeding animal and will likely pass it on to her pups and potentially the male dog that she's bred with. The probability of zoonotic transmission is low. Leishmaniasis is not directly transmissible from dogs to people under ordinary circumstances. But if it were to occur, the impact would at least be moderate because the owner is immunocompromised. Now, I think an argument could be made that this impact could also be high, depending on the nature of the owner's condition. And while the probability of vector-borne transmission is moderate, the impact would be high if Daisy were to reside in a densely populated area, for example, So from this step, we select the greatest impact for inclusion into step 5. And so from the list of things we just talked about, the greatest impact is high. Next slide. In step 5, we determine the final risk estimate using this table. Let's look at the left side of the table first, which is the combined risk of importation and transmission from step 3. That one we said was moderate. And so next, we'll look across the top of the table, which is the impact assessment from the So then we look to see where those two intersect on the table, which results in an overall risk estimate of high. So once we've established the overall risk, we can look at mitigation strategies to reduce that risk. And that's the point of this tool, to establish the risk and then figure out how to mitigate it. And here, we're really focusing on strategies that prevent transmission between dogs and from dogs to humans. This can include things like consistent use of sample preventatives, excluding infected dogs from breeding and blood donations, utilizing standard precautions in veterinary practice and avoiding needle sticks to prevent iatrogenic transmission, and encouraging immunocompromised people to take extra precautions when handling infected animals. Next slide. Okay, so let's go back to Daisy. So we've completed the risk assessment, we've established that there's a risk, and now we need to decide what to do. So first, always check and comply with any state or local regulations regarding the disposition If allowed, consider contacting both the owner and the receiving veterinarian if that veterinarian is known. For the owner, it would be a conversation on the requirements of regulations that exist, but beyond that, potentially counseling them on strategies to reduce the risk of further transmission. If you have the authority, consider requiring the dog to be spayed, although in this scenario, that would be likely a contentious conversation, considering that Daisy is intended to be a breeding animal. For the veterinarian, it would again be a conversation on requirements of regulations, if any exist. And then beyond that, considering whether treatment is a possibility, the importance of appropriate stand-by preventives for this patient, and ensuring that the veterinarian can counsel the owner on this issue and has access to prescribe those, ensuring they're aware of the possibility of iatrogenic transmission and know the steps they can take to protect themselves and their team, and restricting the dogs from any blood donation programs that the hospital might have. Next slide, please. So that concludes our presentation on the Operational Risk Assessment Tool. Thank you so much for your time and attention today, and we are happy to take questions at the end. Thank you. Excuse me. Thank you, Drs. Peterson and Straley. Oh, we're on the right slide. For our next presentation, Canine Leishmaniasis, Country-Level Risk Assessment, will be shared by Dr. Sheena Tarrant. Please begin when you're ready. All right. Thank you. Good afternoon, everyone. Next, please. Every year, an estimated 1 million dogs are imported to the United States, including personal pets, service animals, rescues, and working dogs. Many of these animals are coming from countries where a Leishmania species may be endemic. Next slide, please. Now, when we're trying to estimate the risk of Leishmania introduction associated with dog importation, either in general or for a specific dog, knowing whether L. infantum is endemic in the country of origin is a critical component of the assessment as shown and discussed in the figure that Dr. Straley was just talking about, the Operational Risk Assessment Tool, and was discussed previously. Now, historically, that information has not been readily available for many countries. The resource that we're presenting today was created in an effort to fill that gap. Next, please. So, who is this resource and risk assessment tool intended for? Next. CDC's primary mission is to protect human health, and as part of that mission, we have regulatory authority over dog importation in order to prevent the introduction of zoonotic diseases, including canine Leishmaniosis. Our veterinary medical officers are on call to perform public health assessments if imported dogs appear ill on arrival. Next, please. Department of War veterinarians also oversee the international movement of large numbers of dogs through their role in caring for working dogs and service members' personal pets. The tool that we are presenting to you today was first developed to support CDC and Department of War veterinary medical officers in their daily operational work. Next, please. Although CDC and Department of War veterinarians are the first line of defense to identify imported cases of Leishmaniosis, it's important to remember that many Leishmania infections in dogs are asymptomatic, and Leishmaniosis screening is not required for all dogs imported to the United States. Private veterinarians can play a critical role in identifying animals that become sick after arrival if they know when to consider Leishmaniosis. Next slide. To illustrate why this resource needed to be developed, I would like to introduce you to Elijah. That's not his real name, but these photos and the information that we're about to present about him are from a real case. Now, Elijah is a middle-aged intact male German Shepherd who was evaluated by a private veterinarian at a CDC-registered animal care facility. CDC regulations required him to have an exam and rabies vaccination on arrival because he was traveling from a country that is considered high risk for canine rabies. During the exam, he was found to be underweight with a rough, thinning hair coat and crusting lesions on his ears. When signs of illness are identified in an imported dog, a CDC veterinary medical officer is called in to perform a public health assessment to rule out diseases of zoonotic concern. So, what differential diagnoses would you be considering if you were the CDC VMO assigned to this case? Next, please. So, again, this is that probability scale that Dr. Peterson and Shrailey were just discussing, and that is focused on individual risk factors for canine Leishmaniosis. So, we've established that Elijah is not clinically healthy, and he's also not one of the high-risk groups listed here, such as strays, shelter dogs, and working dogs. However, the most important thing we need to know to decide where to place him on this scale is whether he has been in an endemic country. His owners report that he has been in Guatemala for the past three months, and before that, he lived in Lebanon. Is canine Leishmaniosis endemic in these countries? Until recently, there was no centralized resource that we could use to quickly find this information. Next slide. Now, ideally, disease risk assessments would be based on comprehensive global surveillance systems using consistent methodology, but that type of data is not available for canine Leishmaniosis. So, we elected to conduct a literature-based risk assessment instead. We worked with a CDC librarian to compile a library of articles published between 2019 and 2023 about Leishmaniosis and sandflies. We then established a team of reviewers who were assigned specific countries to evaluate based on the articles included in that library. Next, please. So, there was no pre-existing method for determining canine Leishmaniosis risk in a specific country or area, but we wanted to make our risk assessments as objective as possible. So, we developed a rubric that reviewers used to score countries based on the information available in the literature. Assessments focused primarily on evidence for the presence or absence of canine disease in suitable vectors. However, a country's risk score could be reduced slightly if they conducted surveillance for canine disease, had vector control programs in place, and or they had canine vaccines or treatments available. We did not weigh these preventive factors very heavily because it was often difficult to obtain reliable information about them. Now, while we mostly focused on canine disease, in countries where there was no information on disease in dogs, we did also consider the presence of Leishmaniosis in people, but only if the reference specified that it was caused by L-Infanto. Unfortunately, we found that many sources of human surveillance data did not specify the species of Leishmania involved. Next slide. We quickly discovered that many countries were not mentioned at all in the library of articles assembled from the literature search. For these countries, we developed a standardized list of additional resources that we could consult. These included the World Animal Health Information System, the WHO's Human Leishmaniasis Risk Maps, and a publication from 2011 that included detailed country-level Leishmaniasis information in its supplemental information. If we still could not find any information in these sources, the country was not given a risk score. Most of the countries that fell into this category were small islands or territories. Next please. We then performed two types of quality control. The first was conducted at the reviewer level. At least 20% of every reviewer's country risk ratings were independently reviewed by a second reviewer. If inter-observer agreement was low, then all of the initial reviewers' ratings were reviewed by a second observer and differences were resolved through discussion by the project leads. Next slide. The second quality control step involved reviewing the generated map for countries whose risk scores were dramatically different from neighboring countries. This was an important step because there was the potential for a country to be classified as low risk simply because of poor data availability. Any discrepancies were flagged for review by subject matter experts and changes based on SME review were carefully documented. Next please. The final result is this map of canine Leishmaniasis risk that is publicly available through PubMed Central. An alphabetized table containing the same information is also available for easy reference. Next slide. So if we go back to Elijah, the dog we saw photos of previously, you will recall that Elijah had traveled to Guatemala and to Lebanon. It is a little bit difficult to see on this map just due to size, but both countries are considered high risk for canine Leishmaniasis. Based on his clinical signs and his travel history, Elijah was tested for Leishmaniasis and his results came back positive. Next slide. It is important to remember that literature-based risk assessments are only as reliable as the data that underlie them. We found that data were lacking for many countries. While we hope that these country-level risk assessments will prove a valuable tool for clinicians and regulatory officials, they are not a substitute for good clinical judgment. Leishmania testing should still be considered for dogs traveling from low-risk countries if their clinical signs are strongly suggestive of Leishmaniasis. Next slide. This project required detailed review of a lot of literature, and we could not have done it without our team of reviewers. We would also like to thank the subject matter experts in the parasitic disease branch who generously shared their expertise during this project. Next slide. You can download the full text of the article for free from PubMed Central, and be sure to download the supplemental materials as well to access the country-level risk assessments in an easy-to-read tabular format. Thank you. Thank you, Dr. Tarrant, and thanks again to all of our presenters for sharing this tool and walking us through the risk assessment today. We have a few, we have some time for some questions. As a reminder, if you have a question, please use the Q&A feature to send your questions and include the presenter's name or topic. Okay, we're going to start off with one of the first questions that came through for the first presentation. Why or how are imported dogs assumed to be representative of all the dogs in the U.S.? I can take a first response, and then Anne can correct my explanation. So, in trying to put together this model, we do find that dogs are brought from many different places in many different health statuses, and the breed representation, although not exactly the same as the United States, is pretty close. So, because of that and, you know, not being able to really assume otherwise, it was easier to build this tool based on previous tools, i.e. the rabies tool, to make that assumption. Yeah, correct. Sorry, I just couldn't get to unmute fast enough, but Dr. Peterson said it great. Thank you. Okay, staying with the first presentation, got a question about current recommendations if a needle stick occurs to veterinary staff after the needle was used to draw blood from a positive dog. Can you weigh in? So, for needle stick events like that, it's kind of approached on a case-by-case basis, and so I would encourage folks to have, if they are the ones who have had a needle stick injury in the situation, to go and see their health care provider, and if their health care provider has questions, to contact CDC's Parasitic Diseases Branch, and we can put the email and the phone number for that in the handout that goes out afterwards, or you can drop it in the chat. They're a great resource for those kinds of questions. Okay, thank you. I think there is a way to, if you want to reply to the specific question in the Q&A by putting the email, you can do that if you want, or one of us can put it in the chat as well. Thank you. Okay, I'm going to paraphrase here, staying with the first presentation again, but for Dr. Peterson, have any changes in weather influenced the sandfly distribution or range? I'm going to repeat what I heard as the question and then answer it. So, what I heard was, is there any indication that weather can change the range or distribution of sandflies, particularly in the United States? Is that what I'm answering? Yes. Great. Yes, so there is evidence. Sandflies are small and fuzzy, so they don't fly very well, and in very windy conditions, they really choose not to fly at all. As you might imagine, then they aren't going to transmit much if it's very windy because they're not going anywhere. It's also true in very rainy periods, they really don't like flying around again because they've got these wings that are covered with lots of little hairs, and they would basically drown. So, both wind and rain definitely make a difference. Thank you, and as I move on to another question, if you want to look at the actual question that I paraphrased, you can write in the comment, but I won't verbally repeat the question. There may be a difference between what the participant asked and what I just asked, but we won't capture that on this call. I'm going to go moving on to another question, so leaving it up to our presenters if you want to write in an answer. Okay, so next question, and I'm not sure who this might be for, which presenter, but we occasionally receive questions from practicing veterinarians regarding or subsequently asking questions on next steps for positive dogs. As the COSAHO, it is not currently a reportable disease, and we don't have a lot of resources available. I typically refer these to our SPHB for guidance or follow-up. Would you recommend this be a reportable disease with specific actions in states? Unless Anne is burning to answer that question, I guess I'll take a shot at it. I'm not familiar necessarily with the acronyms, so people can help me with that, especially not being able to see them, but I believe WOA, formerly OIE, did list leishmaniasis as a disease of interest. Different states have considered it in different ways. I'm a firm believer, having listened to Sue Montgomery a lot from the CDC, that it's important when you make something reportable that you have something to be able to do about it, and in this instance, there isn't a federal body who really has power to do something about it, so I'm not sure reportability is going to improve anything and just will add paperwork to already overworked people, but happy to hear other thoughts on that. No, Dr. Peterson, I would echo that, and really the way the public health system is set up in the United States, it's up to the states to determine what conditions they would like to make reportable within their jurisdictions. Thank you. Okay. We have a couple questions that are kind of following the same theme about, and it may go back to what you guys just answered about having to do something about the cases, so one question is, why are we allowing the importation of known infected dogs into the U.S.? Will there be any restrictions imposed by CDC to address this before it becomes a widespread problem? And there's also a statement about rescue groups bringing in dogs that are knowingly infected, and the attendee mentioned it's a matter of time before competent vectors start to become part of the life cycle in various parts of the country. Any answers or comments to that? So I can address this one a little bit, but essentially when we are examining what additional regulatory restrictions should be put in place, you know, we have to consider the potential risk of introduction or reintroduction of disease into a location where it does not currently exist, and the potential impact of that introduction in animal health. So re-evaluations of regulated diseases really are performed based on that risk. Okay, thank you. I am not seeing any new questions that we haven't addressed. Please let me know, presenters, if you see something in the Q&A that I didn't mention. If you're looking at the Q&A, I know I'm reading it out for you guys. I, yeah, I'm looking through right now. So if you have additional questions, we have our presenters' names and emails on the slides, and I do believe that, I'm not sure if we were able to get that email in, I can read it out, or if you guys have the email and want to just mention it on the call right now to answer the question about the needle stick occurrence, or the scenario, sorry. That's okay, I did put it in the Q&A. I don't know if that's actually visible to anybody else, but it's really easy to remember. It's parasites at cdc.gov. Great, thank you. Okay, okay, so we'll conclude our Q&A. Thank you again for answering those questions and addressing comments. If you have, sorry, I already went over that. You can email, as I said before. Please join us for the next SOHU webinar on Wednesday, June 3rd, and thank you for your participation today. This will end today's webinar, and we hope to see you next month. Bye.