Tuesday, August 27, 2013

Laws and consequences: Texas legal changes in excruciating detail

On the face of it, the recent changes to Texas state law appear to be a good idea, aimed at preventing non-veterinarians from practicing veterinary medicine. But as is often the case with legislation, digging in to the situation a little deeper uncovers a load of unintended consequences, in this case in animal shelters. The whole story makes a great teaching case for how population medicine differs from individual medicine. There's a lot to cover, so let's get going.

The body of law in question is the Veterinary Practice Act. This Act covers, you guessed it, the practice of veterinary medicine. Among the basic rules that the Act lays out is the rule that in order for veterinary medicine to be legally practiced on an animal, there must exist a valid veterinary-client-patient relationship. That statement takes quite a lot of unpacking, so here you go:

  • Veterinary medicine: in this case, giving a vaccination
  • Valid veterinary-client-patient relationship: the relationship between the veterinarian, the client, and the patient. The veterinarian must have actually met both the client and the patient. Usually this must be renewed yearly -- so if you call your veterinarian and ask for a refill on your pet's medication, but you haven't had your pet in to the clinic for more than a year, the veterinarian must ask you to bring your pet back in for a checkup, or the veterinarian is at risk of losing their license. (Seriously. That's why they won't refill over the phone after a particular period of time.)
  • But there is an exception made for herd health. If the veterinarian is treating a herd of animals (commonly livestock such as cows) then the relationship is with the herd, not the individual animal. So the vet can prescribe treatments over the phone for a herd member that they haven't ever seen, if they have recent experience with that herd as a whole.
In the case of an animal shelter, some states treat animals in a single shelter as a herd. This is entirely appropriate. In a shelter, medicine should be practiced with the good of the population at heart, not the individual animal. I promise that this is not as heartless as it sounds, and ends up actually being better for the individual in the end. If you let parvovirus get a hold in your shelter, it is the herd that is sick, but it is individuals that die. It is best for individuals to be in a healthy herd.

Until recently, the situation in Texas was that it was legal for a non-veterinarian shelter employee to give vaccines to animals in the shelter because they were members of a herd, so the veterinarian could write general herd health protocols ("give the core vaccines to all animals at intake") without having to see each individual animal. Now that's changed.

The problem is with stray animals. Shelters don't own stray animals for the first few days that they are in the shelter. This is called the animal's "stray hold," and is intended to give the owner a chance to reclaim their animal before it is put up for adoption. The number of reclaimed stray animals is typically low, especially for cats; often only 2% of stray cats are ever reclaimed. The majority of stray animals go on to be owned by the shelter.

Texas has changed the wording of their Animal Practice Act to specify that dogs and cats cannot be considered herd animals. Yes, it has really taken me this much explanation to get to the actual change in wording, but here it is: in the middle of a definition of the veterinary-patient-client relationship, the Act states (newly added text in italics):

A veterinarian possesses sufficient knowledge of the animal for purposes of Subsection (a)(2) [having a valid veterinary-patient-client relationship] if the veterinarian has recently seen, or is personally acquainted with, the keeping and care of the animal by:
(1) examining the animal; or
(2) making medically appropriate and timely visits to the premises on which the animal is kept. (NOTE: Per TAC 573.20(b) and 573.80(14), this section only applies to herd animals not including cats and dogs.)

On the one hand, it does seem silly to think of a "herd" of dogs and cats. But if you forget about the fact that the word "herd" has other meanings in other contexts, the real question that this change in wording is addressing is: Should shelters be allowed to practice population medicine on their animals?

In this particular instance, the fallout goes like this:

  • By default, shelter animals in Texas cannot be treated as "herd" animals.
  • Animals which are owned by the shelter are exempt from the Veterinary Practice Act, and therefore may still be treated as a herd.
  • Stray animals which are still in their stray holding period, however, are not yet owned by the shelter and therefore are not part of the shelter's herd.
  • Therefore, stray animals in their stray hold period must be examined by a veterinarian before receiving any treatment, including initial vaccines.

Not a big deal. Surely all shelter animals are examined by a veterinarian, right?

Actually, in quite a few shelters, veterinarians are only called in to treat sick animals, and the healthy animals are managed by technicians. Even in shelters which have a veterinarian, it is common for the veterinarian to only see sick animals. Of course, it is in the best interest of the animals for a veterinarian to see all of them as they come in the door, to establish a baseline of health status and to identify any problems that a technician might miss. But even in shelters with this policy, an animal may not be seen by a veterinarian for several days. Shelters are chronically understaffed and the vets are often behind on performing physical exams, as they have to prioritize treating sick animals more highly than checking on healthy ones.

Even in shelters which are fully staffed, it may be the next day before an animal is seen. If an animal comes in at the end of the day, the veterinarian may be in surgery the next morning and not get to physical exams until the following afternoon, so that the animal isn't seen for about 24 hours.

So the animal isn't seen by a vet for a day or three. If it's healthy, that shouldn't be a problem.

In the case of a shelter animal, one thing must happen the minute it comes in the door to the shelter: it must receive its vaccines. Prompt vaccination, right at the time of intake, is crucial in keeping animals healthy in shelters. Vaccination takes several weeks to bring the immune system up to its full efficiency in dealing with a pathogen, but there does seem to be an effect much earlier than that. Just a few hours one way or the other can actually make a difference, most critically in the very young and susceptible animals (did I mention in any previous posts how crazy kitten season can be in some areas?) and in the very dangerous diseases (such as parvovirus, which often simply manifests as dead animals with no warning). But don't take my word for it. The bible of shelter medicine, the Guidelines for Standards of Care in Animal Shelters, has this to say about prompt vaccination:
Because risk of disease exposure is often high in shelters, animals must be vaccinated at or prior to intake with core vaccines... Shelters that do not vaccinate with core vaccines immediately on entry, or do not vaccinate all animals, are much more likely to experience deadly outbreaks of vaccine preventable disease (Larson 2009).
This is how it works: the animal comes in to the shelter, either as a stray or surrendered by an owner. It gets processed, minimally receiving an identifying number, and is placed in a cage or run. Whoever performs this processing can either stick the animal with vaccines (and give it dewormers) at that time, or call a technician to do it. Giving vaccines isn't hard and you can train just about anyone to do it: it's technically easy (though it's nice to have someone else around to hold the animal still), and no decisions are really necessary. If the animal is too sick to receive its core vaccines against the most dangerous shelter diseases, it is too sick to be in the shelter and should get transferred to a hospital or other off-site care. Period. They all need their vaccines.

I'm saying this as someone who vaccinates her own animals much less often than conventional veterinary wisdom would have me do it. Shelters are full of disease and stress, and decisions about when and how to vaccinate there are going to be very different from decisions about animals in a home environment. I can't say it too often: without prompt vaccination, animals in shelters will die. The first question a shelter medicine specialist asks upon being confronted with an outbreak of parvovirus or distemper is "Are your animals vaccinated on intake?"

So, finally, on to this recent legal change in Texas. What shelter specialists see coming like an impending train wreck is lots of stray animals in Texas not getting seen by a veterinarian as soon as they are brought in to the shelter (it is not reasonable to expect that the vet could see them immediately); therefore, those animals not getting prompt vaccination; therefore, sick animals in shelters. Lots of them.

There is legal recourse at the city or county level: each city or county with a municipal shelter can change its ordinances to appoint the shelter the "designated caretaker" of stray animals during their hold periods. This allows the shelter to once again consider stray animals as part of the shelter herd, so that the veterinarian may ask someone else to give the vaccines before a physical exam has been performed. I have no real idea how likely it is that cities and counties will pass such ordinances, but I am guessing that the rate of adoption won't be anywhere near complete, and that the speed of adoption won't be blinding.

What's the moral of this story? I'm not really sure, but I think it has something to do with how complicated the consequences of legal wording can be, and how important it is to take the advice of specialists into account. I send my sympathies to Texas shelter veterinarians, who now will be faced with the scramble to still vaccinate stray animals on intake despite the change in laws.