Education as a Tool for Disease Management: Elephant Endotheliotropic Herpes Virus Case Study in the United Kingdom
Management of emerging infectious diseases often relies on front line staff having access to available information and being able to recognize clinical or pathologic symptoms of the disease before the disease can be reported. Elephant endotheliotropic herpes virus (EEHV) is an example of a devastating, emerging infectious disease that is thought to have a carrier or latent status within an animal and can be present within a herd for a long period before clinical signs are seen. This paper describes the importance of educational material combined with a lecture program directed towards veterinarians, elephant keepers, and collection managers as part of the United Kingdom’s (UK) National Elephant Endotheliotropic Herpes Virus Programme.
Elephant endotheliotropic herpes virus (EEHV) is one of the most important emerging diseases of elephants that has implications for the future of captive as well as wild population management programs. The first death due to EEHV reported in an Asian elephant (Elephas maximus) occurred in 1988,2 but the disease was not officially described until 19963. Despite being recognized for over 10 yr, still little is known about the epidemiology of this disease. In 2005, the first suspected case of EEHV was seen in the UK with a herpes virus being isolated in utero from a calf at postmortem. One month later, a confirmed case of EEHV occurred in a 3.5-yr-old calf that died within the same herd. One year later, an unrelated, third case of EEHV was confirmed by gross lesions and PCR.
National EEHV Program
In response to the first case of EEHV, the concept of a National EEHV Programme was considered. By 2007 this had become a reality and was developed to provide an educational need and support structure both for clinicians and collections that housed elephants.1
It was realized early on that the first line of management of EEHV would rely on the knowledge of keepers reporting suspected cases and introducing EEHV checks to daily routines. However, despite keepers being aware of the disease, the knowledge of the lesions of the disease, and the actual ability to identify signs that could potentially be related to EEHV varied between keepers. This variation was not dependent on length of elephant experience but was related to individual interest and self-driven research. The level of knowledge varied from little or no knowledge of the disease, to keepers with a reasonable general knowledge of the disease, to other keepers that had been misinformed about certain details of the disease. A key part of the management of the disease required education of the elephant keepers. The key for EEHV management is early therapy and this requires early recognition systems to be in place, principally through keeping staff.
The education program was developed with three tiers of elephant-related workers targeted. The first, most obvious, tier was the keeping staff themselves where material was provided to allow identification of lesions, understand the pathology of the disease, and to identify possible outcomes and basic concepts of disease spread within and between herds, with details on how to liaise with the collection’s veterinarians and other institutions.
The second tier concentrated on the veterinarians working with the collections that housed elephants, both African (Loxodonta africana) and Asian. Refresher courses were provided to the veterinarians through lecturing and the publication of technical manuals.
The third tier included the curatorial and collection managers from zoos that contained elephants. The educational aim here was to provide technical support but also to explain the potential outcomes of infection being confirmed within a herd, the potential costs of therapy, and the long-term management recommendations for moves and reproduction.
The primary aim in all of the tiers was to increase awareness of the disease, understand the implications and potential costs to a collection, increase EEHV surveillance through a central body, and to provide a regularly updated point of information that would vastly improve response time for suspected cases.
The UK National EEHV Programme education department considered that the priorities for education should include the following.
A poster campaign was targeted at all of the United Kingdom and Ireland’s elephant houses. This was primarily aimed at the elephant keepers to ensure that there was an easily accessible source of photographs of lesions and clinical signs. The poster, in addition, included a quick list of therapeutics and samples required for testing providing a concise review of EEHV in a flow chart format. The aim was to increase knowledge and have a local, in-house reference chart if keepers (or veterinarians) were concerned that a potential case of EEHV was occurring.
A tour of all of the collections that housed elephants was undertaken. The target audience was primarily elephant keepers, but also included the veterinarians and collection managers. Slide presentations concentrating on EEHV but including tuberculosis, and other management-related diseases were given depending on the requests of the individual collections.
In addition, EEHV-specific presentations were provided at national and international veterinary conferences to provide updates on recent research and to re-iterate the importance of early therapy and variation in the gross clinical signs seen within the UK (e.g., oral ulceration had not yet been seen in any of the UK cases).
A technical manual reviewing all aspects of EEHV etiology, history within the literature, epidemiology, pathology, clinical signs, therapeutics, diagnostics, husbandry and management recommendations, and references were provided in an electronic format to all of the collections. This manual was peer-reviewed for accuracy by clinicians in the EEHV international task force from the USA and Europe. Although aimed at clinicians, elements were relevant to managers and keepers, especially the comprehensive collection of images of the gross clinical signs.
In addition, a leaflet was produced which focused on the lesions and clinical signs with details of further sources of information being provided. This was included with the poster campaign.
The educational campaign was part of a larger UK National EEHV Programme which included a famciclovir depot and delivery system, and an epidemiologic study of UK elephants. However, for the successful management of individual cases of EEHV the most important aspect of the program was early recognition by keepers with an efficient reporting system put in place.
This program demonstrates that the management of any emerging infectious disease often relies on staff on the ground at the front line being the key for identification and subsequent management of any disease outbreak. For any disease management program, these all important front line staff need to be educated and informed as changes occur within the literature and this educational need must not be forgotten about when designing a management program.
Thanks are due to colleagues at ZSL and Port Lympne for their unfailing support during trying times when managing EEHV cases. In addition, my thanks goes to Dr. Thomas Hildebrandt, IZW, and Dr. Willem Shaftenaar, Rotterdam Zoo for their help with the initial development of the UK National EEHV Programme. Not forgetting Erin Latimer, National Zoo and Dr. Lauren Howard, Houston Zoo, for their advice on diagnostic testing and therapeutics, respectively.
1. Cracknell, J.M., A. Routh, D. Field, W. Schaftenaar, T. Hildebrandt, and S. Hewitt. 2007. Elephant endotheliotrophic herpes virus (EEHV) in the United Kingdom: an update with the development of the National EEHV Management Programme. Proc. 43rd Inter. Sym. Dis. Zoo und Wild Animals. Pp. 60–63.
2. Ossent, P., F. Guscetti, A.E. Metzler, E.M. Lang, A. Rubel, and B. Hauser. 1990. Acute and fatal herpesvirus infection in a young Asian elephant (Elephas maximus). Vet. Path. 27:131–133.
3. Richman, L.K., R.J. Montali, R.C. Cambre, and J. Lehnhardt. 1996. Endothelial inclusion body disease: a newly recognized fatal herpes-like infection by Asian elephants. Proc. Am. Assoc. Zoo Vet. Pp. 483–485.