Fleas: Fables, facts, and proven solutions (Sponsored by Merial)

Clarify misconceptions.

Understand flea biology.

Lead your practice to confi dently implement clear solutions.

Participants:

Michael Murray, DVM, DACVIM Merial Limited, Duluth, Ga.

Sam Reichman, DVM Flat Creek Animal Clinic, Fayetteville, Ga.

Michael Dryden, DVM, PhD Kansas State University, Manhattan, Kan.

Michael Canfield, DVM Florida Veterinary Specialists, Animal Hospital of Regency Park, New Port Richey, Fla. Animal Emergency and Referral Center, Fort Pierce, Fla.

Christine Rees, DVM, DACVD San Antonio Veterinary Referral Specialists

Recently, veterinary parasitologist and flea expert, Dr. Michael Dryden, met with a veterinary dermatologist and two progressive practitioners to discuss the concerns and misconceptions that clients, staff, and veterinarians have about flea control—and to come up with clear solutions for the perplexing problems surrounding this issue.

The discussion begins with the misperceptions that lead pet owners to question why they are still seeing fleas on their pets after treatment. But it isn't just clients—team members also may be harboring misinformation and old wives' tales that can easily be passed along to clients. So how do you educate your clients about the true facts surrounding these important parasites?

Once these facts are laid out on the table, the discussion moves to the heart of the matter—the essential facts about flea biology—and finishes with practical, proven solutions to effective flea control.

Client questions and misperceptions

Dr. Michael Murray: What questions do you and your staff hear from clients about flea control products? Do they complain that flea control products seem less effective?

Michael Canfield, DVM

Dr. Sam Reichman: Yes. The first big complaint is that the products are not working anymore. Clients say they applied it a week ago and are already seeing fleas. Secondly, they complain about cost—which becomes an issue when they think the product isn't working.

Dr. Michael Canfield: "Why do I still see fleas?" is a frequent question, and clients automatically blame product failure. It doesn't matter how many fleas are in the house or their yard—they still think the product isn't working adequately.

Murray: What proportion of your clients do these pet owners represent?

Reichman: It used to be small, but it has increased over the last two years.

Christine Rees, DVM, DACVD

Dr. Christine Rees: I've seen more flea-allergic dogs in the last couple years. Some people think the product is not working as well. Or the owner puts the flea control product on and expects the fleas to disappear—instant gratification. It takes time to educate them that one application won't solve the problem.

Dr. Michael Dryden: My experience has been similar to the rest of the panel—the perception that products aren't working like they used to, or clients are complaining that they put the product on and are still seeing fleas. Internet chatter has perpetuated some of this belief that things may be falling apart. I was just in Lincoln, Neb., and practitioners expressed that sentiment—that the products were working fine for them, but rumor has it that it's not working in other places. They want to know how soon it will happen in their area.

Murray: So that may create an expectation in the veterinarian's mind that he or she will be seeing problems eventually, and they may begin to think there is a flea product problem.

Sam Reichman, DVM

Dryden: Without a doubt.

Murray: Pet owners come into the practice and complain that they are still seeing fleas after treating pets. Who do they talk to first about this?

Reichman: The receptionist, because that is the person they see first. Then the technicians. All flea control questions used to be asked in the front office. The receptionists gave flea and product advice and told clients how to use it. Complaints never got back to me until about two years ago. That's when things started going off track. Then people who we knew were using the product correctly said they were having problems. That's when complaints came to me.

Canfield: Our receptionist or customer service people get the questions first. Then it filters to the technicians. The receptionist would put a note in the computer saying the client was unhappy because the flea control product wasn't working and they'd spent money on it. The technician got the second round of questions. By the time I got to the exam room, the clients would be riled up.

Mike Dryden, DVM, PhD

We recently educated the entire staff about flea biology, and now, in most cases, they are able to manage these complaints. It has lightened my workload regarding flea and tick control. I still end up dealing with a few complaints because the client wants to hear it from me, but educating our staff has helped take some of the burden off the doctors. The clients I usually get are those with flea-allergic dogs, in which the owners never see fleas.

Interestingly, clients give different answers, depending on who asks the question. They seem to give it additional thought between the receptionist and the technician. While they may tell the receptionist that the product isn't working and the pet still has fleas, they may tell the technician that they've been visiting a relative with the dog each weekend, "and she doesn't do anything for flea control with her two dogs." Or, "I go to the dog park every weekend." Usually they are finding the problem.

Murray: How does your team respond to a complaint of reduced effectiveness? Do you think they're confident to deal with these concerns?

Reichman: They are now. But when we started noticing the problem, everybody had the same knee-jerk reaction. It must be the product's fault, and the first thing we did was switch products.

Dryden: I'm hearing similar things from veterinarians. There are so many different products available that it has been almost a crutch to just swap products.

Murray: Are there times when switching products works?

Dryden: Yes. There are biologic reasons for that. If you start with a certain product, use it for several weeks until the life cycle is about to collapse, then switch to another product, things can get better fast. The last product you use gets the credit for solving the problem. Once you start using an effective topical or systemic product, you are killing fleas and preventing, or drastically reducing, further reproduction. Therefore, the flea life cycle collapses once all eggs have developed into larvae, all the larvae have developed into pupae, and all the fleas have emerged. The collapse usually occurs in three to five weeks.1,2 This explains why switching products at this time makes the second product look great. I've seen that happen with over-the-counter products where a veterinary-prescribed product apparently wasn't working—but it really was. Then three or four weeks later you switch to an over-the-counter product, and now it usually works within a few days. The life cycle was already collapsing.

Sam Reichman, DVM

Murray: Have fleas been trivialized to some extent? Are they considered more of a nuisance parasite than a health-related problem?

Reichman: The clients look at fleas as insects—little bugs in the house, like roaches and ants. Clients still think of them as little bugs that jump from one animal to another. With other bugs, they get a little spray or the bug guy comes and sprays. They don't see ants or roaches anymore. So why are they still seeing fleas? In their mind it's just another bug.

Dryden: When I first started in flea research, fleas were the purview of the entomologist. And that was because no veterinarian had ever done flea research. The dermatologists had done work on flea-allergy dermatitis (FAD), but other than that, flea studies were basically done by entomologists. We would throw insecticides and foggers at them, but we never really approached fleas as a medical problem.

Murray: What are some of the most common misperceptions that pet owners have about fleas?

Rees: Some clients think that one application of something makes bugs and the problem disappear.

Murray: And Dr. Reichman, you mentioned they see them as bugs that jump from one animal to another.

Reichman: Yes, they focus on that adult stage and miss the fact that a flea has life stages. They don't consider the egg, larvae, and pupae stages. They just worry about what they see, which is the adult flea. They consider them like any other bug—they jump around, biting their dogs and cats and leaving flea dirt behind. The dog scratches and chews all its hair out. They don't consider the life cycle and the fact that a host is involved. This is different from the ants and bugs around the house.

COMMON MISPERCEPTIONS: THE VETERINARY CLINIC

Murray: Dr. Rees, are client misperceptions the same in a referral situation?

Rees: Flea denial is the biggest misperception I see.

Canfield: Clients will tell you they don't have carpet so they can't have fleas.

Rees: Or the cat is an indoor cat, so how can it have fleas?

Dryden: And some people believe fleas are a social stigma.

Rees: The cases I see are FAD with the classic distribution pattern. The owners say, "Well, it can't be flea allergies because I don't see fleas." But you can tell from looking at the dog that there is obviously a flea problem. In those cases, you have to educate clients so they believe that their pets have a medical problem caused by fleas.

Murray: How do you get the pet owner's attention, particularly in situations where they don't think there's a problem? Dr. Canfield, you mentioned an effective technique.

WHAT CLINIC STAFF MAY NOT KNOW ABOUT THEIR CLIENTS FLEA PROBLEM

Canfield: It's a useful technique to convince clients that there might be fleas around that they can't see. When they're in the clinic, I suggest that I keep their pets overnight, just to observe them, bathe them, etc. Usually by the next day the household fleas are hungry, and without a pet host around, they find their way to the clients' ankles. It's a convincing argument for disbelievers.

Murray: So pet owners' perceptions are based on their experiences, and yet their reasons for seeing or not seeing fleas essentially relate to numbers and other biological factors. How does this relate to the environmental situation, Dr. Dryden?

Dryden: First, pet owners tend to see fleas when there is a larger environmental emergence resulting in a significant flea burden. You also need to consider different hosts—people generally see fleas more easily on dogs than on cats. Then you further compound that with whether that dog is flea allergic. If it is, it's grooming and ingesting fleas. It isn't that one flea caused this problem, but the dog is grooming so effectively and ingesting so many fleas that by the time it's examined by the dermatologist, the dog has chewed off the remaining fleas. There might have been 20 fleas three hours ago and now there are none.

Murray: You mentioned the self-grooming. In those situations you would expect clients to see or complain about tapeworms and not as much about fleas.

FLEA BIOLOGY: KEY FACTS

Canfield: Absolutely. They will come in for an exam and tapeworm deworming, and hopefully that's when the doctors and the staff can educate them about flea control issues and measures.

Dryden: Clients don't understand that fleas have a complex life cycle, and they don't understand the association with the host. Often clients don't consider that where their pet plays or walks can be the problem. For example, we evaluated a German shorthaired pointer that had over 500 fleas on it when we went to the house to investigate. There was a massive infestation under a tree in the backyard. When you walked toward it, fleas were all over you. The woman was treating her yard with diazinon. I asked her why she didn't treat underneath the trees and bushes, and she said she couldn't treat there because that was where the dog slept. So she was completely missing the connection between the fleas laying eggs or falling off and causing infestation while the dog was sleeping. We need to provide more education about what is actually causing the problems.

Murray: Where do pet owners think these fleas come from?

Reichman: The yard. In our area, most lawn care companies market flea control treatments, too. They apply an insecticide—an adulticide—when they fertilize the lawn. This may help with spiders, but it won't do much for the fleas. They are thinking about adult fleas and envision them jumping onto a dog when he runs through the yard, but that's not where they are coming from. They are ignoring the rest of the flea life cycle.

Canfield: Clients often do not understand that where their pet goes can be a source of their fleas. If they live in an apartment

THE KANSAS SUMMER OF 2008: FIT FOR A FLEA

with an area designated for walking dogs or visit dog parks, the dogs are sharing the flea burden of other dogs that may not be treated. I think of these pets as the living "salt and pepper shakers," meaning that flea eggs and feces are falling off them wherever they go. I don't think clients tie that together.

Dryden: Clients will say their dog didn't meet other dogs. But that's irrelevant because encountering another dog does not elevate the risk because the fleas don't jump from dog to dog or cat to cat.

People also think that a permanent indoor cat can't get fleas. Yes, it can. We've even seen flea problems in houses without any pets because these fleas have hitchhiked a ride on the people in the house. It happens frequently.

Murray: We've discussed the misperceptions about how pets get fleas. What are the common misperceptions that pet owners have about flea control products?

TOP 10 REASONS FOR PERCEIVED FLEA CONTROL FAILURE

Dryden: A few years ago I listened to phone calls with the Merial technicians. Many of those calls were simply that someone treated a dog two days ago or last week or yesterday and they wanted to know why they were still seeing fleas. There was an expectation of immediacy.

Canfield: Clients assume that one dose will kill all the fleas. They think that after they apply the product they shouldn't see another flea.

I think that as a profession we have become complacent; we don't tell clients that the fleas we're seeing today came from infestations that began weeks ago. The eggs, larvae, and pupae are already in place. In two to eight weeks from now there will be more. They will have to kill them, and they may still see fleas. That's difficult for clients to understand. They expect the problem to disappear once they apply the product.

Murray: Is that perception affected by the advent of modern flea products, compared with all the dips and shampoos that we used to use?

Reichman: We never used to talk in terms of not seeing any fleas. If you saw a couple you were happy that your efforts were working. Then you'd treat flea allergy. We didn't have the control that we have now with topical products.

Dryden: The perception has been that modern products kill immediately. Treat the pet once and the fleas disappear. I hear from practitioners that when the topical products first came on the market, they appeared to kill immediately, and that one dose got the job done. But I think that's a misperception. I don't think these products ever worked that way. I went back and looked at the data from field studies that we did in Tampa in 1996 through 1998.2 Guess what we saw on the dogs after we applied *ADVANTAGE® or FRONTLINE®? Fleas. They never disappeared instantly. The numbers decreased dramatically but when we treated a dog with these products in a flea-infested house and came back on day seven, we still found fleas on those pets. We were able to get to a zero-flea state in a home and on a pet in 90% to 95% of the homes within six to eight weeks in 1996 and 1997. In a few homes we still had a flea or two after 90 days. Generally, it took about three months of regular monthly treatments to wipe fleas out completely in those early studies between 1996 and 1997. It is no different today. Somewhere between 1996 and 1998, we developed a perception that, after giving a dose or two, fleas rapidly disappear. But the data from our field study never showed that.

WHAT CLIENTS DO NOT KNOW ABOUT FLEAS CAN HURT THEIR PET

So it's a perception issue, not a reality issue. I think that perception occurred because the new products in the mid-1990s were so much better than what we had prior to that time.

Rees: Also, the newer flea products were not as labor intensive as the weekly dips and powders. Everyone was happy they weren't having to do as much, and it seemed to be working better. Everybody got used to the once-a-month application.

Dryden: We also know from those data sets that the problem could get worse for several weeks, usually three to four weeks, before it got better because the fleas you see today came from eggs laid six to eight weeks ago. Depending upon how many eggs were laid previously and what the environmental conditions were like, you could literally have a massive emergence going on in an individual home. We had those homes in 1996 and 1998 and we have those today. I'm not sure that I am actually seeing anything different today than I saw back then. There are times that it appears to occur on a greater scale, but I can generally explain most of that based upon climatic and ecological factors, such as the amount of rainfall and humidity.

Canfield: I wonder if we were more compliant and less complacent when the products first came out.

Dryden: That is a profound statement. Because flea infestations were so bad, we were probably more diligent and compliant. Then, over the last decade, we let it slip away. One of the common mistakes that clients make is not applying these products regularly. Once an animal has fleas, it is probably going to get them again. We did a three-year study in the mid 1990s where we went into the homes monthly or every other month.3 Over the next three years, every single home had a recurrence of an infestation.

FROM PROBLEM TO PROBLEM SOLVER TAKING CONTROL

Canfield: Everyone is busy, and applying a flea product slides to the bottom of the to-do list.

Dryden: Another factor is that clients are often not aware of how the environment and climatic changes affect fleas and their perceptions of products not working. A pet owner in Tampa told me he tried FRONTLINE and ADVANTAGE and neither product worked. When I asked him to elaborate, he said he tried ADVANTAGE for a few months and the fleas went away, but when he stopped using it, the fleas came back. So he put the dogs on FRONTLINE for a few months and the fleas went away. He stopped the product and the fleas came back. He literally thought that once they were gone, they would never come back.

Doctors and staff perceptions

Murray: So the client believes that once she applies a product, fleas should stay away forever. How does the clinic team, doctors included, evaluate the situation when the fleas come back?

Dryden: As a profession we've become complacent over the last decade with a variety of new, extremely good, flea products. We rely on these products, and if they don't work, we give the client another product to use and they are satisfied.

Instead, we need to educate the client up front about what to expect once the product is applied. We have to talk about the life cycle within the pet's environment and the emergence of fleas. We need to tell clients that they are going to be battling this problem for at least six to eight weeks until it's under control. That's the way it has been and that's the way it is now.

Murray: Do you think that the effectiveness of veterinary flea control products has decreased in recent years?

Reichman: The fleas are still dying, but it seems to take a little longer.

Canfield: Do you think fleas are living longer or do you think the flea burden is greater? Yes, the product concentration starts to wane over time but I don't think our external burden of fleas is waning.

Murray: Dr. Dryden, from a flea biologist's perspective, do you think the products have the same effectiveness or are there other factors contributing to perceptions of reduced effectiveness?

Dryden: We've studied this at Kansas State University and we cannot document selectional resistance causing product failure with these modern products. The data that we generate in our lab indicate that these products are working as well as they've worked from their inception. We've had concerns. Anytime you use any kind of a drug—insecticide, antibiotic, etc.—you're always concerned about selection for resistance. But we haven't been able to document that at this point.

Rees: I asked the question about drug resistance at a recent veterinary conference. The majority realized that other reasons, such as climate changes and compliance issues were factoring into fleas being noticed by owners after a flea treatment application. Hopefully that viewpoint is a result of continuing education about flea control.

Dryden: After a lecture I gave in Florida this year, one veterinarian said, "You don't understand. In the last six months every product has failed me." His frustration and his problems were real—there was no doubt about that. He listed the products he was using — five to six completely different active compounds that have completely different modes of action. The resistance mechanism would be completely different for all of them. It wouldn't even be biologically possible for the fleas to be resistant to all of them at once. But he truly believed it, and he walked out that day still believing that there was resistance to every product he had.

Practitioners need to understand that we have the appropriate tools to get the job done. But it requires understanding and implementation of integrated flea control. How many practitioners understand that when using an adulticide and insect growth regulator (IGR), we are practicing integrated flea control? And how many forget to talk to clients about washing their pet's bedding or vacuuming the carpets or washing the throw rugs? I think this incredible complacency has seeped into our profession. Sometimes I'll ask an audience how many of them educated clients about flea control prior to 1995—virtually all of them raise their hands. When I ask how many do that now, maybe three or four people in the audience are still providing client education.

So many good products came out that we just started throwing insecticides at fleas without educating clients. Now we have clients that have no concept of how to effectively control fleas. They treat this dog and this cat once and think the fleas will be gone tomorrow. It's never worked that way.

Murray: Shifting gears a little bit, what are common misperceptions that veterinarians and veterinary staff have about flea biology?

Reichman: The staff needs to be educated about the life cycle. I think we underestimate how long the pupae stage can hang around without seeing adult fleas.

Our clinic staff was thinking about the adult flea and forgetting about the rest of the life cycle. That means forgetting about the potentially huge numbers of fleas that can develop over a short period of time from outside sources that have nothing to do with us not applying the product properly or treating the pets.

Canfield: We also don't always consider where the pet spends its time. There are certain places clients shouldn't take their pets because of exposure to a high flea burden in the environment. The misconception is that we assume a treated pet is free of fleas and can go anywhere. I don't think that is necessarily the case.

Rees: And if people see one flea, they forget that it's a small part of the life cycle that they are seeing. It gets exponentially worse. If you just see one flea you have a big problem.

Murray: What misperceptions about flea biology do you encounter in a referral practice?

Rees: Probably that veterinarians don't have to educate clients about treating the environment. Some practitioners may not even realize that the owner has several pets unless it accidentally comes out in conversation. I'm fortunate because I have more time to talk with clients and may get more information.

Canfield: One of the misconceptions in our practice is that we are selling flea control and assume clients are truly using it on all their pets, when they may not be.

Dryden: In my experience, most of these problem flea cases occur in multiple pet households. This goes right back to the fact that they might not be treating every pet.

Murray: So when the client brings in a dog that still has a flea problem, the clinic team might not understand why that is, because they are not aware that there are other dogs or cats in the home that are not being treated for fleas.

Dryden: The failure to treat every animal in the household is a huge issue. Clients bring in the scratching dog, but you never see their untreated cat.

Canfield: And we don't routinely ask about that.

Murray: Dr. Reichman, how does your practice make sure that all the pets in a household are being treated?

Reichman: The technicians ask clients if they are treating all pets. From our files, we know how much product they are getting over certain time periods and we ask if they are using additional products. We assume their answers are accurate, but we can also tell from our files if they might be slighting one pet or undertreating, based on the amount of product purchased. Sometimes the dog that sleeps in the bed with them might be treated, while the outdoor pet is ignored. And sometimes it is an economic issue. We work with a retired couple who has four or five dogs, and it's hard for them to maintain monthly flea control.

Murray: Are there other common misperceptions?

Reichman: Staff may think the products kill 100% of the fleas. Therefore, if they are seeing fleas it must be drug resistance.

Murray: Do you think your staff understands how the products work?

Canfield: I gave a quiz to my practice staff. I thought they knew it all, but they didn't do very well. Questions they missed included, What is an insect growth regulator? We need to work with the team on these areas. We need to educate staff members continuously, particularly in the area of flea life cycle.

Flea biology: the life of a flea

Murray: This moves us into a discussion of flea biology. Where do fleas actually come from?

Dryden: The fleas that are on the dog and cat or that bit you on your ankle emerged out of cocoons. Those pupae came from larvae, which came from eggs generally laid six to eight weeks previously. This is the life cycle that generates adult fleas. That flea that is on your dog or cat has never been on another dog or cat. That flea that bit you on your ankle has never been on a dog or cat. Fleas come out of the cocoons and they jump on the first host that goes by. If it is an appropriate host, that is where they are going to stay until they die.

Murray: What are the most favorable environments in the home and yard for that life cycle to succeed?

Dryden: Temperature and humidity are important. Temperature dictates how rapidly the life cycle generates and humidity determines how many larvae are going to survive. Generally temperatures between 70 and 85 degrees Fahrenheit are fairly ideal.4 Seventy percent to slightly above 80% humidity is ideal. Once the temperature gets above 95 degrees consistently, the life cycle collapses.

A good example of environment affecting flea control is what happens seasonally in the Midwest. We have a surge in flea populations every fall. It happens like clockwork. The weather shift that occurs in the fall moderates temperature and increases humidity. Additionally, wildlife in urban neighborhoods—such as opossums and raccoons—are good cat flea hosts, and the conditions for sustaining fleas on these animals improves in the autumn because the climatic conditions allow for greater larval survival. Animals also have more restricted grooming, due to increased haircoat density in the fall. The opossum is an example. During the height of the hot, dry summer, less than half the opossums have cat fleas on them. By the time you get into September, October, and November, 100% of opossums have cat fleas.5 The number of fleas on each animal can be in the hundreds—our record was 1,009 on a single opossum living under a trailer.

This condition contributes to what we hear each fall: Product A worked great all summer, but now it doesn't work. It has nothing to do with resistance. It has everything to do with numbers. Three to four weeks after an application, the level of insecticide decreases. The speed of kill decreases. Efficacy is no longer 100%. If a dog or cat has five or six fleas you don't see them. But if a dog or cat has 40, 50, or 60 fleas, guess what? You will see fleas.

Or we can have a season in which the weather isn't conducive for rearing fleas in a certain area, but the next year it could all turn around. It ebbs and flows.

Temperature and humidity are also important for microclimates in homes. For instance, nylon-fiber carpeting can absorb from 2.5% to 3% of its weight in water.6 It is a remarkable humidity buffer for larvae in that environment. If fleas were intelligent they would erect monuments to nylon-fiber carpeting because it does such a remarkable job of maintaining a humidity buffer. Not only that, it also collects the dander, debris, and flea feces that these larvae need to feed upon. So it is a remarkable three-dimensional matrix for flea larval survival within a home.

Canfield: If there isn't carpet, flea debris and larvae will gather in cracks in the floor. The wood wicks moisture as well.

Murray: And outdoors, shaded areas or areas protected from rainfall and sunlight are optimal areas, correct?

Dryden: Yes. The shaded, protected outdoor microhabitats are where flea development occurs. Direct sunlight beating down upon a lawn is not conducive to any larval survival. In hot, dry environments, fleas are going to succumb. Also, the larvae need flea feces. In weather that is hot, dry, and lower humidity, fleas are going to succumb.

Murray: Flea dirt, then, will be found where the pet is spending his time in the yard when it's hot?

Dryden: Yes—and where wildlife might rest during nocturnal visits—under porches, shrubs, bushes, and crawl spaces. We talked about the saltshaker concept—the eggs falling into protected, shaded areas as the animals move through the environment. Nocturnal animals like raccoons, opossums, foxes, and coyotes tend to follow transit lines—along fence lines, bushes, and shrubs. These are the locations from where fleas will emerge.

Even if a client only has an indoor cat, that cat can get fleas. Fleas hitchhike. They jump on the homeowners, and they carry them inside where they hop onto the cat. I've even seen infestations in homes where there are no pets, though fleas can't sustain themselves on humans.

Reichman: Pet sitters are a huge business—and maybe contribute to the hitchhiking effect. Some members of our staff do it at lunch and then come back to work. I wonder if they could be potential carriers.

Dryden: Easily. That's an issue that we all have to deal with—the hitchhiker flea. I've found fleas on me after working in the yard. It happens.

Murray: What can a client do to the yard to protect pets against these outdoors sources of fleas?

Dryden: The most important thing a pet owner can do is to identify sites on the premises that pets or wildlife may use as shelter. These include crawl spaces, areas under decks, porches, or stairs, and shrubs and trees. Prevent access to any of these areas if possible.

Applying insecticides to an open yard won't help diminish a flea problem, but if directed to the shady protected microhabitats, it will help. I generally recommend a hose-end sprayer. Turn the water on, hit the trigger, and it self-meters out. Clients should be warned not to allow children or pets access to that area until the material is dry, which can be several hours. Be sure to read the labels.

Murray: How long is this effective against the flea? And what stage of the flea life cycle is this affecting?

Dryden: Primarily we are affecting adult fleas as they emerge. That is why these are approved for once-a-week application. They are probably effective until a heavy rainfall occurs.

Murray: So you are not ridding the yard of fleas, but knocking down the populations as they emerge from the pupae?

Dryden: Right. There is so much organic debris and dirt that you won't affect the eggs, larvae, and pupae to any great extent. But this does help.

Rees: How long does it take to get flea populations under control after a bad flea problem?

Dryden: In our Tampa studies, we sometimes found 1,000 to 5,000 fleas on an individual animal. We can get to zero flea state in 95% of those homes within six to eight weeks.2 Those are our data over the years. There will always be individual cases that take longer, particularly in temperate climates in the fall of the year. You may battle emerging fleas for 90 to 120 days in some homes because it is cooler.

Murray: We experienced this in Clearwater, Fla., where the pet owners had been using FRONTLINE® Plus on all the pets for several months but were still seeing fleas. It was because every time the dogs went outside to use the yard they would come in with one or two fleas. The flea infestation in the house was gone, but they could still see fleas on the pets. That is an important expectation to reinforce. Getting rid of the flea problem and infestation in the home doesn't necessarily mean they will never see a flea on their pet—and that's because the pet is going outside.

Rees: Would treating the environment have sped up the process?

Dryden: To a certain extent, but treating the yard won't get every pupa.

Reichman: What about air conditioning?

Murray: Air conditioning will actually take some of the water out of the air in the house.

Dryden: The problem, especially in some parts of the country, is with the humidity. We see homes in the Midwest with infestations that last into the winter because people are humidifying their homes.

Solutions

Murray: Dr. Reichman, you mentioned that one of the first steps in getting your hospital staff to confidently discuss fleas with clients was improving your own knowledge of flea biology, flea control products, and how the products work. Is that correct?

Reichman: Yes, initially when we saw fleas after treating, we just switched products, but that didn't help the problem. Around the middle of last summer, when we were knee-deep in flea complaints and problems, we changed products. This just left the staff confused. Finally, I realized that the problem wasn't the fleas or the products—I was the problem. There was no engagement on my part. At that time, flea control had been out of my hands for years. The products were at the front desk and the only thing I saw was the company invoice. I couldn't remember the last in-depth flea control or flea life cycle talk I'd had with a client. I wasn't prepared for the problem that was occurring, and I didn't have a good solution because I wasn't treating it like a medical problem.

Dryden: We have to elevate fleas to the level of preventable medicine. We often don't approach it that way. Fleas frustrate clients and cause great distress for many pets. Flea control generates a lot of money for a lot of practices. I think we should give it the respect that it's due, elevate it to the level of a medical problem, and handle it appropriately.

Reichman: I began approaching the problem like I did any other serious medical issue. First, I re-educated myself on flea biology. Once I started looking at it from the entire life cycle standpoint, it made sense. And I worked on it from that angle. These products are working—but our problem has gotten bigger than what we are used to dealing with. We had to start attacking the problem like we should have been doing all along.

By the time I see clients now, my staff has talked with them about why they may be having flea control problems, and the clients look to me to provide solutions. I have become the problem solver.

Murray: That seems to be a good process because instead of being on the defensive with the pet owner, you are in the position that you should be. The person that is making the recommendation and the problem solver.

Reichman: I began teaching my staff about the flea life cycle again. We all began talking to clients about what product they were using and how they applied it. I started asking questions about treating all pets and explained how the products work and that they are not 100% effective.

I started doing my job and talking about fleas again, speaking face-to-face with the client and explaining that it wasn't a resistance problem but a much bigger picture. We were expecting too much.

Murray: So an important component of your success was your confidence and the confidence of your staff in understanding flea biology and the products?

Reichman: I think they also see that I am more sure about what I am saying, so they feel more confident about what they are saying to the client. We are talking about perceptions. If you perceive that someone is confident in what he or she is saying, you are more apt to become confident yourself.

My staff isn't afraid of it now. They discuss flea biology with clients. They'll say, "Dr. Reichman will be here in a minute, and he'll go over treatment options." When I come into the exam room, the client is already receptive. Instead of being defensive about the situation, I am ready to provide solutions. The clients are getting on board and realizing this is not a quick fix.

Murray: Dr. Dryden, you speak to veterinarians and technicians around the country. Have you seen a change in the approach the clinic staff has toward flea control? What key things have practices done to make the staff confident about discussing flea control?

Dryden: Dr. Reichman's experience is similar to that of many practices. Engagement with the client on flea control has virtually ceased—from the veterinarian to the technician to the front office staff. The key has been getting the staff educated to the level they need to be to deliver the message to the client. This effort has to start at the top—the veterinarian has to explain why it's important and deliver a consistent message to his staff. The client has to get the same message. If they get one message from a receptionist and a different one from a technician and the veterinarian, it won't work. In a multiperson practice, everybody has to be on board. The staff has to set the clients' expectations. Once treatment is initiated they need to know what is going to happen. Setting proper expectations is crucial.

Murray: How can practices initiate a discussion that covers the key points about flea control in a routine office visit?

Dryden: One approach is to ask, "What are the foundational parasites in your practice?"

In many places in the Northeast it's the tick and tick-transmitted diseases. There are often parasites that the client is familiar with. Heartworm is a big one in dogs. In cats it may be ear mites. Then immediately expand on it. Tell them that heartworm is a big issue and their dog needs to be on a heartworm preventive. But they also have to be concerned about fleas, ticks, and intestinal parasites. So we start with the foundational parasites and then explain how to provide the pet with a healthy environment and how to prevent disease from many other parasites.

Murray: So you are getting their attention by discussing a parasite that's important to them?

Dryden: That's right. Then immediately expand the dialog to include a comprehensive parasite prevention message.

Practitioners find this useful. They are able to expand the discussion and put the pet on a broad-spectrum parasite prevention program. You have made the inroad to move right down the list: Fleas and heartworm. Ear mites. Ticks. Roundworms. In cats the foundational parasite is frequently fleas or ear mites because clients are familiar with them. Even though we know that feline heartworm disease is very important, it is not tangible to many clients yet. Depending upon where you regionally practice, your foundational parasites will vary. Practitioners know what the foundational parasites are in their particular area, and they can expand from a discussion of that parasite to a broad-spectrum prevention approach, preventing parasitic disease.

Reichman: A client may perceive heartworm to be a more serious health risk because it can kill the dog, so it gets their attention. Clients are afraid of ticks because they get them on themselves. They may just look upon the flea as a nuisance, but if you treat it as a disease-causing agent like these other two, you can hold their attention.

Murray: Are there any other key messages for the pet owner regarding flea control products and using them successfully?

Reichman: Pet owners should understand that they are not alone in this. It's not just their house, but also the neighbor's home and a fellow in the next county. Everybody is experiencing the same problem.

Murray: Reassure them that it's a common problem, but there are solutions to the problem.

Reichman: Yes, It's not that they're doing something wrong. Some

people were doing what we told them to do. We just weren't telling them all the things to do.

Dryden: I think the final objective, once the staff and clients understand flea biology and how the products work, is that you can't stop once the problem is over. The fleas will come back. There are too many sources in the environment for these fleas. Whatever therapy we are using, we have to continue. It's a lifelong process.

Canfield: Like heartworm prevention.

Dryden: Yes. Dental health is another good analogy.

The dentist looks in my mouth and says, "Mike, you've got cavities. What's happening?"

"Well, Doc," I say, "we found out last year that brushing and flossing worked so well I decided to stop."

We laugh at that, but we do the same thing with flea control. We use the product and wipe the fleas out. It works so well that we stop, not realizing that this is no different than any other type of preventive medicine. You can't stop. You just roll right over from treatment into prevention.

Murray: What is the most effective thing your practice has done to help clients successfully use flea control products?

Canfield: Educate the staff. That's the number one thing. Our staff and ourselves. If we don't educate each other, then it doesn't matter what product we're using.

Murray: What do you see with your educated staff that you weren't seeing before?

Canfield: They identify problems and help solve them, instead of just handing out another product. That is key. That's what we do as doctors—identify the problem and then treat it. We all have to hone our problem-solving skills.

Murray: Does your staff enjoy that role of problem solving?

Canfield: They are excited about what they are doing. But the education process never ends. Periodically, we close down for a couple hours at noon and review medical concepts. I think it helps employee retention when clinic staff has this kind of responsibility.

Dryden: In many practices the technicians take a history. The flea control history can be part of that process, but technicians need to know what to ask.

Murray: Dr. Reichman, has education made a difference in how your staff handles flea problems?

Reichman: They are more confident interacting with the owners, even clients who are upset because the fleas have returned. The receptionists have more ammunition now to diffuse problems because they know the reasons that the fleas might be back and can explain it to the client.

Murray: Are there any tools that are especially effective in educating staff about flea control?

Canfield: I use a flow chart that starts with spotting a flea to asking the number of pets in the house, to how many animals are outside a home, including stray cats, opossums, or raccoons. Once they go through it a few times, they are down to the correct answer quickly and it takes little time.

Murray: So your staff goes over that with the pet owner?

Canfield: Yes. They give it to the client to take home. Of course it doesn't cover everything.

Reichman: I find that nothing replaces a one-on-one conversation, looking at someone and explaining it clearly. If you speak confidently, they will learn about flea control from you and you will learn about their pet's environment from them.

Murray: In thinking about how to best use the office visit, what do you think pet owners want to know about fleas and flea control products and what is the best way to communicate this information?

Reichman: They want to know the truth about what is going on. We are supposedly the experts and that's why they are asking us. They want a solution to the problem.

Dryden: With consultation cases, I often find that once we start dealing directly with the problem, the pet owner is relaxed and more receptive.

Canfield: We educate clients about the flea life cycle and the developmental stages that can occur in the home, so we set expectations that they'll still see fleas for awhile. This turned things around for my practice. Previously, we told clients that if they used the product, the fleas would be gone—but they are not. You can't do anything about the ones that are already in the environment that have yet to emerge. They are still coming and there is nothing you can do about it.

Murray: That is critically important. Clients want to know what to expect. They want to understand the basics of the problem but in the context of how that leads to a solution. Now, what do pet owners need to know about fleas and flea control products?

Rees: The importance of treating all animals.

Reichman: And continuing treatment. It's not a short-term fix. You have to stay with it.

Dryden: They need to know that they can still see fleas and the products are working just the way they are supposed to.

Canfield: Particularly if they are picking up new fleas every time they go outdoors.

Dryden: This situation occurs with every product. It is an industry-wide issue. Again, it's a misperception. We have to let clients know what is going to happen.

Murray: To sum it up, what do pet owners need to know about fleas and flea control products?

Dryden: We covered this previously, but it's worth repeating. The fleas on the dog and cat and the fleas that bit you emerged out of cocoons or pupae.

Those pupae came from larvae, which came from eggs generally laid six to eight weeks earlier.

The flea that bit you has never been on a dog or cat, and the flea that is on your dog or cat has never been on another dog or cat. They come out of the cocoons and they jump on the first host that goes by. If it is an appropriate host, they will stay there until they die.

And those fleas are laying up to 40 to 50 eggs per day on that untreated animal.

If you do not treat every potential flea host, every dog or cat within that home or yard, you cannot win this war.

References

1. Dryden M, Perez H, Ulitchny D. Control of flea populations on naturally infested dogs and cats and in private residences with either topical Imidacloprid spot application or the combination of oral lufenuron and pyrethrin spray. J Am Vet Med Assoc 1999;215:36-39.

2. Dryden MW, Denenberg TM, Bunch S. Control of fleas on naturally infested dogs and cats and in private residences with topical spot applications of fipronil or imidacloprid. Vet Parasitol 2000; 93:69-75.

3. Dryden M, Brown H, Buck S, et al. Effective long-term protection against flea infestations. Veterinary Medicine 1998; June: 16-18.

4. Dryden MW, Rust MK. The biology, ecology, and management of the cat flea. Annu Rev Entomol 1997;42:451-473.

5. Portis MJ, Dryden MW, Broce AB. et al. Seasonal variation of wildlife distribution and ectoparasite load in the urban environment, in Proceedings. 7th Int Symp on Ectoparasites of Pets, League City, TX, 2003;35.

6. Dryden MW. Personal communication, 2008.