My trip to Nicaragua was filled with amazing opportunities to grow as a professional, as well as a person. I was exposed to a culture and way of life very different than my own and was working in an environment that has many technological challenges. The clinic was not for profit and was forced to practice without the luxury of machines such as an ECG, radiology, and IDEXX machines. The veterinarians in the area were adept at making diagnoses based on clinical signs and history alone and nearly always their treatments were successful. I had the opportunity to perform numerous elective procedures on stray canines and felines. While in Nicaragua I performed spays, complicated spays, spays on pyometras, neuters, hernia repairs, and participated in an amputation of a forelimb. In addition I saw numerous consults for the local population and was required to evaluate patients, create treatment plans, and perform any and all procedures. I was amazed at how much I had learned in the past three years of my life and with the aid of the veterinarian I was able to utilize that knowledge to heal and help the animals in the area. I was finally helping in a way I have been studying for and the fulfillment I felt made all my hard work worthwhile.

I was fortunate enough to work with horses and it was interesting to see how differently horses are treated in Nicaragua.  They are used as workhorses and their health is pertinent to the income of the families that own them. They suffer from problems such as saddle sores because they are commonly overloaded by wood, hay, and other life necessities.  Laminitis is very uncommon and the horses are generally never overweight. I was also fascinated to see bites from vampire bats. I saw diseases I never expected to see as a veterinarian as I never planned to practice any medicine outside of the United States.

In addition to working in the area, living in the area was fascinating. Stray animals were abundant in the city and many of the strays I sterilized found me again while I was at a restaurant or walking down the street.  Small business stands, singers, and children playing in the street created a rich cultural environment.  Most people do not drive but rather walk where they need to go. Internet was intermittent and not having a cellular telephone allowed me to appreciate the lifestyle and culture of the area. I was enriched as a person and the growth I experienced far outweighs the fears I had associated with travel overseas. I would say to any student considering studying overseas to jump at the opportunity for my life will be forever changed by the things I did in Nicaragua.

UNAM is the AVMA approved school in Mexico City.  For students daring enough to practice their medical Spanish, this is an excellent school to visit and stay for a summer or for a few rotations during fourth year.  While it may not have neurology or cardiology specialties, let’s be honest… practicing medical Spanish will be challenging enough!  Some of the more likely areas students would like to study in would be equine medicine, small animal medicine, exotic animal, poultry, swine, or avian medicine.  As I have a strong interest in exotic animal medicine and did not know much about pet birds, I decided to study at the Hospital de Aves, or bird hospital during my 6 week professional development period.  During this time, I performed basic chores such as cleaning cages and giving food to the birds.  Additional daily tasks included daily treatments of the birds in the clinic and taking clinical histories from clients who came for consults.  I had several of my own patients, and when clients came to visit their birds, as the doctor on the case, I would update owners to the condition of their bird and any new developments.  Throughout my time at the bird hospital, I was given tours of all of the remaining 14 buildings at the veterinary hospital of UNAM.  Additionally, I was allowed the opportunity to take avian medicine classes with Dr. Morales and practice surgical techniques and necropsies.  The most challenging part of this experience will be to perform all medical tasks expected of you at any veterinary hospital and to communicate them with owners fluently in Spanish.  This is an excellent opportunity for anyone, and is a definite skill set that is invaluable in large cities or in areas where the Latino population is prevalent.  What I found to be most interesting at my stay at the bird hospital is that while the clinic knows the treatments for birds that we are accustomed to, sometimes the drugs were not available or too expensive to feasibly afford.  As such, the clinic is resourceful enough to find alternative medical treatments that suffice until the drugs become available to Mexico.  Additionally, the UNAM avian hospital has a board-certified avian veterinarian.  This is a great time to be had by anyone willing to undertake this excellent and challenging learning experience.

Students participated in the boma set-up, mass capture, and tear down process, which spanned several days.  Mass game capture and relocation included species such as blesbok, hartabeest, zebra, and wildebeest.  Several times, there was only a tarp curtain separating you from the animals.  On the second day, I even caught a female blesbok by the horns as she tried to escape!

Throughout the trip, there were daily lectures ranging from chemical immobilization to snake handling, and ample opportunities for hands on experience.  Placing a catheter in a white rhino’s ear prior to dehorning, sexing crocodiles, and monitoring a white lioness’s breathing during her spay surgery were among my numerous first hand experiences.

Additionally, we assisted Dr. Raath’s drug trial on crocodiles, which included calculating and preparing dosage, drug administration, and monitoring breathing and immobilization.

Other activities included treating a juvenile male hippo’s wounds, dart preparation and shooting practice, and assisting with the work up on a darted roan, cape buffalo, white rhino, and sable.

We even had the unique opportunity to necropsy a two-month-old rhino, which revealed a severely underdeveloped left ventricle.  Witnessing 4 of the Big 5 at Kruger National Park and observing the picturesque view of God’s window, were among the many beautiful sites on this trip.

The course offered a fantastic and unforgettable experience in wildlife and international veterinary medicine and solidified my career interests in both.

There was ample opportunity for practicing physical exams, anesthesia techniques, venipuncture, endotracheal intubation, and Esophagostomy tube (E-tube) and catheter placements. Additionally, a group project was assigned in which we had to record data on an area of endangered Acropora cervicornis (Staghorn coral) while scuba diving! Working in two teams, we divided the area in half and assigned various jobs for recording overall health, measuring diameter, assessing degree of bleaching, and documenting the coral’s location via triangulation. Leisurely evenings included ocean view dinners, kayaking after dark on a bioluminescence tour, and a dusk dive along the North Wall, seeing three eagle rays.

One free day was allotted in which we ventured on a morning dive exploring swim-throughs and were completely surrounded by a school of silversides. To top it off, the afternoon was spent at Stingray City. The workshop was the perfect blend of intriguing lectures, plenty of hands on experience, and free evenings to explore the beautiful Grand Cayman Island. This course was a remarkable experience and confirmed my interest in aquatic and conservation medicine.

Marvet was a vast surprise.  There was a strong emphasis on conservation, but there was also an intense emphasis on public health.  The public health aspect both surprised me and intrigued me, due to my strong interests in public health and disease control.

We started out at Dolphin Discovery, which is a marine park near where we were staying at Playa del Carmen, Mexico.  The first few days were primarily lectures from various experts in the field of marine mammals.  We were taught about the animals, everything from basic physiology to reproduction and common diseases.  The veterinarians and dolphin trainers from the marine park also lectured us.  The emphasis of the lectures from the park was primarily on how to work together.  Both the trainers and the veterinarians emphasized respecting each other’s jobs and realizing that both careers need the other.

On the second day, we were able to learn about the feeding habits and digestion of manatees.  We were able to feed and then snorkel to observe the park’s manatees underwater.  During our time, we also observed a voluntary dolphin ultrasound and voluntary dolphin endoscopy.  The park works hard to train their animals to do voluntary medical procedures in order to reduce the use of anesthetics in their animals.

Later that week, we moved to Xcaret, another marine and ecotourist park.  While there, we were able to learn about and work with green sea turtles, nurse sharks, sting rays, fish, and manatees.  My favorite experience in Xcaret was learning to catch the sea turtles in order to draw blood on them.  While we still were in an enclosed pond, we were actually able to swim out, catch, and then maneuver the sea turtles into a more secluded section of the enclosure.  Once we had the turtles restrained, we drew blood, using the jugular sinus, cleaned off the shell for aesthetic purposes, and then released them.  We also had the opportunity to handle and to draw blood on sting rays.  We later did a dissection on a sting ray and a green sea turtle, both of which had died of natural causes.  The comparative anatomy was striking between these two species and our more common mammalian, domestic species.  One of the final eco-parks that hosted us was dedicated to crocodiles.  We had the amazing opportunity to help catch, restrain, and perform blood draws and injections on adult crocodiles.

As part of the program, we were taken out into the open ocean to visit the whale shark feeding grounds off the Yucatan Peninsula.  We were able to swim with the whale sharks, which was an amazing opportunity.  These animals are unbelievably huge, and it takes an up-close experience to realize the vastness of their size!  For my first time in the water, I was dropped into the open ocean.  I cleared my snorkel and looked and barely fifteen feet away from me and headed directly towards me was the huge mouth of one of the whale sharks!

Even though we were kept busy with lectures and hands-on activities, we were given free time to explore the local area.  There are eco-parks nearby, as well as Mayan ruins.  While in Mexico, I had the privilege of visiting the Mayan ruins, including one of the last sites that allows tourists to climb to the top.  One of my new friends and I went snorkeling on our own and we spotted several sting rays just off the beach where we were staying!

Overall, this was an amazing experience.  If given the opportunity, I would gladly return.  The coordinators of the program are fantastic, and the professors that lecture are very knowledgeable on their respective subjects.  Having the ability to learn about marine mammals and sea turtles not only afforded a comparative basis for more common domestic mammals but also gave me greater experience in public health.  Before this opportunity, I only had a limited recognition of the relationship of public health to marine life and conservation.  Beyond the educational opportunities, I made some priceless contacts in Mexico, both among my peers and among the faculty.

While clearly not a study tour designed for everyone, I strongly recommend MARVET to anyone who has an interest in public health, conservation, or zoo and marine medicine.  The MARVET program is designed for those willing and interested in learning more about these fields.  Students are kept very busy, and there is a large portion of lecture material at the beginning of the program.  However, the knowledge gained through the lectures makes the hands-on activities even more useful and enjoyable.

I was particularly excited for the Koch Institute, not only because it is named after a brilliant epidemiologist but because of its crucial role in controlling and preventing disease in Germany. We heard fascinating talks from Dr. Klaus Stark, Dr. Tanja Ducomble, and Hendrik Wilking, who discussed the Koch Institute’s role in public health as well as their own research.

The Koch Institute tracks epidemiological  data across Germany, providing regular reports for the scientific and medical community and writing medical recommendations for local practitioners. In addition to commonplace outbreaks such as food-borne illnesses and annual influenza, the Koch Institute has preparation strategies for high-risk exotic threats such as Ebola virus.

Our hosts spoke on such diverse topics as the role of vaccination in reducing Salmonella enteritidis infection to the presence of Yersinia enterocolitica in German wildlife. I was surprised to learn that Lyme disease is a problem in Germany as well as in the United States, though ticks in the region carry Borrelia species unknown in the United States, such as Borellia garinii.

After a morning of stimulating scientific discussion, we took the metro to the Berlin Zoo, stopping for lunch at the nearby train station. I was surprised at the variety and quality of affordable food near the metro – I would never dream of finding such tasty curried tofu at Atlanta’s MARTA stations. During the afternoon, we were guided through the historically rich Berlin Zoo by biologist Dr. Renate Foerg. Dr. Foerg spoke candidly about the museum’s history and the problems a modern zoo faces.

Some of the exhibits were very old, such as the giraffe exhibit, which dates back to 1871. I was struck by the fact that several of the habitats feature simulated human dwellings – the giraffe habitat looks like a Middle Eastern palace, for example. Dr. Foerg explained that this is a feature of the changing values of zoos, shifting away from exhibits shaped to human tastes towards more natural imitations of the animals’ homelands.

A particularly charming sight was that of the life-sized bronze statue of a hippo named Knautschke. During the second World War, the zoo was struck by bombs, and Knautschke was thought dead. To the surprise and delight of many, Knautschke actually wandered down to the local train station and survived on his own for several days. This famous hippo bred 34 offspring and lived to the ripe age of 45, five years longer than average.

Dr. Foerg candidly discussed issues such as overcrowding and euthanasia in zoos. One disadvantage of the Berlin Zoo’s location in the heart of the city is that they are unable to expand outward. Instead, the zoo keepers must carefully manage the space they have and

limit breeding that isn’t necessary for conservation. It was clear from Dr. Foerg’s statements that animal welfare is an important issue for the zoo.

Overall, today was an exciting, informative day, and I could have spent weeks discussing infectious disease with the Koch Institute’s scientists, or combing through the diverse wildlife exhibits at the Berlin Zoo.

The evening was spent writing “thank you” notes to our gracious hosts who spent their time so generously with us and enjoying our last German meal together. Joining the University of Illinois Study Abroad Germany program has been one of the best decisions I have made as a veterinary student.

On the anesthesia rotation, I was able to intubate animals, place IV catheters and give IM and IV drugs as well as participate in morning rounds and teaching rounds. I was also able to scrub into and assist in surgeries. It was great to see the similarities and differences between the teaching hospitals in Illinois and Hanover. On the reproduction service I was able to perform vaginascopy exams, prepare and look at vaginal cytology, and assist the clinicians with patients in routine reproductive exams. In addition to the clinical skills that I was able to practice, being at a teaching hospital in another country gave me a great appreciation for how other hospitals and schools are set up.

The University of Veterinary Medicine in Hannover has a brand new teaching hospital with state of the art equipment and technology. One of the aspects of the hospital that struck me the most was how cat-friendly the hospital is. The owner check-in and waiting area is comprised of many small rooms with noise-proof doors so owners can wait with their animals in private. Once admitted to the hospital, cats are taken to a ward two floors above the dogs, also with sound proof doors. There are multiple small rooms in the cat ward, which hold two to four cages, but also have windows and space for the cats to walk around. During my time at the teaching hospital, most of the cats were able to have their own room—while they had beds set up in stainless steel cages, the cage doors were open and they had IV extension sets long enough to be able to get up and walk around the room. Litter boxes were placed outside the cages, which gave the cats significantly more space. Cats that were considered to be painful were given multimodal analgesia that most often included methadone as the opioid. Between the housing set up, pain control and the extreme sensitivity by all members of faculty, staff and students to treat each cat calmly, gently, and with respect (and not as small dogs!), these were the happiest, most relaxed, least stressed cats I have ever seen in an animal hospital.

Overall, the University of Veterinary Medicine was a wonderful place to be. It was great to be able to practice and learn clinical skills, as well as seeing how much impact different set ups and ideas can benefit the patients. Everyone I encountered, from my roommates in the apartment, to the administration who helped me get organized, to the clinicians, professors and students, was enormously friendly and helpful. It was an amazing experience.

After showing us around, Juergen gave us a talk about the history and function of the BfR. It was founded in November, 2002 when the Federal Institute for Health Protection of Consumers and Veterinary Medicine was reorganized. The BfR is essentially the Risk Assessment arm of the former agency, and the Risk Management duties fall on a different organization. This makes the BfR free to conduct independent scientifically based studies without political influence. It is also entirely funded from public sources, and can therefore be independent from private influence as well. The independence of this agency from outside influence has been very deliberately structured so as to eliminate any doubt of bias of their research and risk communication.

The main areas of work for the BfR include food safety (microbial and chemical) and risk assessment, safety of chemicals, plant products and biocides, and safety of selected consumer products and products that contact people indirectly. They are also responsible for independent risk communication, meaning that they do not need oversight or permission from governing bodies or from higher up in the Health Organization. However, they can only give advice; they do not have the power to enforce recalls. And they are responsible for conducting research independent of academic or private research. They also run National Reference Laboratories which monitor infectious pathogens such as Salmonella and E. coli and review methods being used for research of these pathogens. Another area of work is on alternative methods to animal research, which address some animal welfare concerns, but also reduces the cost and time of conducting risk assessment studies.

After Juergen’s talk, we were introduced to Dr. Katrin Stolle from the research coordination unit, who gave us a talk on their research and international collaborations. We were reminded that their main focus is producing quality scientific data for risk assessment, and that any research they do is independent by design. Although they do conduct their own research experiments, they also gather data from other sources, such as the scientific literature, routine surveillance, and self-assessments. The research they conduct is focused on refining methods used in their reference laboratories, supplying data for risk assessments, creating a base of knowledge for communication and perception of risk, and reducing the need for animal experimentation. Much of the national research they conduct is centered in one of their 14 National Reference Laboratories, each of which is focused on a particular pathogen or product. They are also involved in several international research products, including some for QSAFFE (which is a European Collaboration for monitoring food safety), a study on ESBL and flouroquinolone resistance in Enterobacteriaceae, and a study looking for MRSA in the food chain. These international studies are primarily done in coordination with other international laboratories, and funding for these studies comes from sources like the EU, or the European Food Safety Authority (EFSA). The BfR works particularly close with the EFSA, and data sharing, research coordination, working groups and pacts are commonplace between the two agencies. Katrin also talked about the role of the BfR in the EHEC outbreak last year, in which they established a joint committee with the Robert Koch Institute to research the origin of the outbreak, conducted an epidemiological study, and were ultimately able to trace the outbreaks back to one farm that had produced sprouts from Egyptian seeds.

After these two talks, we were brought over to the laboratories where some of the National Reference Laboratories are centered, and we donned lab coats for a tour. Dr. Alexandra Fetsch from the Microbial Toxins unit was kind enough to take us on an extensive tour of the Staphylococcal reference laboratory, including where specimens were first cultured and isolated, and where further identification tests, PCR, and resistance testing were run. They were primarily focused on monitoring Staphylococcus aureus strains for antimicrobial resistance, especially for methicillin resistance. Specimens are collected from production animals directly (ie; cattle, swine, etc.) using nasal and anal swabs, from the environment of farms and slaughterhouses, and from samples of meat. If Staphylococcus is isolated, they run PCR and look for the presence of the mecA gene, which is a mobile genetic element which confers methicillin resistance to the bacteria. Then they are further typed based the spa (staphylococcal protein A) gene, and in some cases by multiplex PCR (if it is of particular interest). The result is a comprehensive food chain monitoring program for MRSA. The results they have found are surprising; apparently in Germany 60% of farms have MRSA in the environment, 80% of slaughterhouses test positive for MRSA, and about 10-20% of consumer ready meat is also positive for MRSA.

The next tour was of the National Reference Laboratory for antimicrobial resistance, which was given by Dr. Andreas Schroeter of the Antibiotic Resistance and Resistance Determinants unit. He also gave us an informative and thorough explanation of what his laboratory did using Salmonella as an example. When they receive a sample, they identify it based on serotype, then on phage type. Once they have established this, they identify whether it is a wild type strain or a vaccine strain. Once they have adequately identified the strain, they run the isolate through a serotiter machine to determine the resistance profile, which they then record. We were shown the lab where they do all of the identification, as well as the resistance profiles. They are also responsible for running similar identification tests and resistance profiles on other food-borne pathogens such as Campylobacter and E. coli. Monitoring these bacteria for resistance is an important for monitoring animal health and food safety. Researchers at the BfR are not only concerned with resistance in these pathogen species, but also hope to gain insight into the resistance present in commensal bacteria of the gastrointestinal system.

After touring the National Reference Laboratories, we had one more lecture given by Eline Basilio-Janke, who gave us a presentation to illustrate food safety studies performed by her unit, Safety in the Food Chain. After the Deep Horizon Oil Spill in the Gulf of Mexico, concern has been focused on the impact of a large oil spill on food derived from the ocean, especially fish and shellfish. In response, the BfR did a study to evaluate the potential for different oil constituents to be concentrated in sea-life (bioconcentration) after dispersants have been used to solubilize spilt crude oil. Based on past studies, they focused on poly-aromatic hydrocarbon compounds (PAHs), which are considered to be the most toxic constituent of crude oil, and of these they focused on four PAHs which as a group are considered to be a good marker of total PAH concentration (there are 16 priority pollutant PAHs). They also chose a scenario that would mimic a North Sea oil spill, using the PAH profile of North Sea oil as the basis for their experiments. From this study, they were able to determine that shellfish, especially mussels, tend to accumulate PAHs much more than fish. With this information the BfR has been able to prioritize the testing of mollusks, especially mussels, in its planned monitoring of the impact of an oil spill on food safety.

Before we wrapped up our visit, we said our goodbyes and visited the on-sight cafeteria at the BfR for lunch. The rest of the day we had to ourselves in Berlin. Some of us went shopping for gifts, while others saw some of the sights they weren’t able to see over the weekend. Dinner was on our own as well, and some of us chose sushi, while others explored the music festival taking place that evening in Berlin. Berlin has a lot to see, so it was easy to find things to do.

RIEMSER’s expertise spans the sectors of Oncology, Dermatology, Dental, and Veterinary work. It distributes nearly 300 products in 94 different countries. RIEMSER manufactures everything from Foot and Mouth vaccines for animals, to oral dental implants for humans, as well as anti-obesity and cardiovascular drugs. RIEMSER also prides itself on maintaining a high level of laboratory and manufacturing safety regulations. These “ good manufacturing and laboratory practices”,  “ GMP’s” and “GLP’s”, allow for strict quality control and a superior product.

A particularly interesting couple of products that RIEMSER manufactures were shared with us. The picture aside displays “ Bite away” and “ Herpotherm”. “ Bite away” is a pen like device used in the moments after an insect bite or sting. The pen is meant to bring relief to a swollen and inflamed bite site. “Herpotherm” works similarly by applying directed heat ( 51-52 degrees Celsius) to the site of a cold sore, which quite effectively prevents the  presence of a blister. These items are as small as a pocket flashlight and are a promising alternative to other therapies! These are only a few of the advances REIMSER prides itself on as they enthusiastically move forward into the future of pharma production.

Vaccine production is now a small portion of RIEMSER’s efforts, but of great interest to our group. We learned that the headquarters of production was in fact the Greifswald location we were visiting. On site, REIMSER  produces a Foot and Mouth Disease vaccine as well as a Swine Fever vaccine. Foot and Mouth Disease and Swine Fever are extremely detrimental viruses on a broad scale, which can severely affect live stock populations across a continent in a short period of time. Thus, the production of these vaccines is of upmost importance to a country’s economy and national security.

Our next speakers served as curators for a wonderful museum of the Friedrich Loeffler institute and RIEMSER lab.  Dr. Sigurd Tesmer, and Dr. Wolfgang Wittmann shared the history of FLI with our group through a plethora of artifacts from the lab’s infancy alongside recollections of the RIEMSER’s successful past. Friedrich Loeffler was the first director of the institute of Hygiene founded in Greifswald,  Germany, in 1888. At one point in his work, Loeffler even worked with the legendary Robert Koch while working in Berlin! Robert Koch is another legendary scientist who is well known for his famous, “ Koch’s Postulates” regarding microbial and disease transmission.

While touring the museum we learned much about Friedrich Loeffler and his influential work with foot and mouth disease. Among his other accomplishments Loeffler also had a mind for public health. Loeffler helped develop a sewer system for the longest street in Greifswald in 1913. Today the very street is named after Loeffler, Friedrich Loeffler Strasse, to commemorate his great contributions. With Loeffler’s passing in 1915, a fellow Veterinarian Otto Waldman, continued Loeffler’s work with the foot and mouth vaccine research. It wasn’t until 1940, that the vaccine was first used on livestock to curb the effects of this dangerous disease. Prof. Wittman explained to us, that at the time the vaccine’s virus content was so low that large quantities were required to be injected to have the appappropriate effect, this was sometimes nearly 40-60mls! In order to solve this problem a unique device was made to safely inject this quantity. (Pictured here is that very device! You can see its long tubing and pump like mechanism used to inject the vaccine once a dose was calculated!)

Today we began our day at the Riemser Arzneimittel AG Headquarters in Greifswald, Germany. Our first speaker, Susanne Böhm, gave a wonderful introductory presentation on RIEMSER and its mission. RIEMSER is a German pharmaceutical company, which was initially a company involved with the production of vaccines for animals and was called RIEMSER Tierarzneimittel. The scientists worked very closely together with the scientist at the Friedich Loeffler Institute on the Isle of Riems. In 1992, the company was privatized by the Braun family. At that time, there were 30 employes. Now, the company focuses its efforts primarily on human pharma products, and some animal products. The company now employs 600 individuals who are spread across Germany, France, and the United States.

RIEMSER’s expertise spans the sectors of Oncology, Dermatology, Dental, and Veterinary work. It distributes nearly 300 products in 94 different countries. RIEMSER manufactures everything from Foot and Mouth vaccines for animals, to oral dental implants for humans, as well as anti-obesity and cardiovascular drugs. RIEMSER also prides itself on maintaining a high level of laboratory and manufacturing safety regulations. These “ good manufacturing and laboratory practices”,  “ GMP’s” and “GLP’s”, allow for strict quality control and a superior product.

A particularly interesting couple of products that RIEMSER manufactures were shared with us. The picture aside displays “ Bite away” and “ Herpotherm”. “ Bite away” is a pen like device used in the moments after an insect bite or sting. The pen is meant to bring relief to a swollen and inflamed bite site. “Herpotherm” works similarly by applying directed heat ( 51-52 degrees Celsius) to the site of a cold sore, which quite effectively prevents the  presence of a blister. These items are as small as a pocket flashlight and are a promising alternative to other therapies! These are only a few of the advances REIMSER prides itself on as they enthusiastically move forward into the future of pharma production.

Vaccine production is now a small portion of RIEMSER’s efforts, but of great interest to our group. We learned that the headquarters of production was in fact the Greifswald location we were visiting. On site, REIMSER  produces a Foot and Mouth Disease vaccine as well as a Swine Fever vaccine. Foot and Mouth Disease and Swine Fever are extremely detrimental viruses on a broad scale, which can severely affect live stock populations across a continent in a short period of time. Thus, the production of these vaccines is of upmost importance to a country’s economy and national security.

Our next speakers served as curators for a wonderful museum of the Friedrich Loeffler institute and RIEMSER lab.  Dr. Sigurd Tesmer, and Dr. Wolfgang Wittmann shared the history of FLI with our group through a plethora of artifacts from the lab’s infancy alongside recollections of the RIEMSER’s successful past. Friedrich Loeffler was the first director of the institute of Hygiene founded in Greifswald,  Germany, in 1888. At one point in his work, Loeffler even worked with the legendary Robert Koch while working in Berlin! Robert Koch is another legendary scientist who is well known for his famous, “ Koch’s Postulates” regarding microbial and disease transmission.

While touring the museum we learned much about Friedrich Loeffler and his influential work with foot and mouth disease. Among his other accomplishments Loeffler also had a mind for public health. Loeffler helped develop a sewer system for the longest street in Greifswald in 1913. Today the very street is named after Loeffler, Friedrich Loeffler Strasse, to commemorate his great contributions. With Loeffler’s passing in 1915, a fellow Veterinarian Otto Waldman, continued Loeffler’s work with the foot and mouth vaccine research. It wasn’t until 1940, that the vaccine was first used on livestock to curb the effects of this dangerous disease. Prof. Wittman explained to us, that at the time the vaccine’s virus content was so low that large quantities were required to be injected to have the app

Today we began our day at the Riemser Arzneimittel AG Headquarters in Greifswald, Germany. Our first speaker, Susanne Böhm, gave a wonderful introductory presentation on RIEMSER and its mission. RIEMSER is a German pharmaceutical company, which was initially a company involved with the production of vaccines for animals and was called RIEMSER Tierarzneimittel. The scientists worked very closely together with the scientist at the Friedich Loeffler Institute on the Isle of Riems. In 1992, the company was privatized by the Braun family. At that time, there were 30 employes. Now, the company focuses its efforts primarily on human pharma products, and some animal products. The company now employs 600 individuals who are spread across Germany, France, and the United States.

RIEMSER’s expertise spans the sectors of Oncology, Dermatology, Dental, and Veterinary work. It distributes nearly 300 products in 94 different countries. RIEMSER manufactures everything from Foot and Mouth vaccines for animals, to oral dental implants for humans, as well as anti-obesity and cardiovascular drugs. RIEMSER also prides itself on maintaining a high level of laboratory and manufacturing safety regulations. These “ good manufacturing and laboratory practices”,  “ GMP’s” and “GLP’s”, allow for strict quality control and a superior product.

A particularly interesting couple of products that RIEMSER manufactures were shared with us. The picture aside displays “ Bite away” and “ Herpotherm”. “ Bite away” is a pen like device used in the moments after an insect bite or sting. The pen is meant to bring relief to a swollen and inflamed bite site. “Herpotherm” works similarly by applying directed heat ( 51-52 degrees Celsius) to the site of a cold sore, which quite effectively prevents the  presence of a blister. These items are as small as a pocket flashlight and are a promising alternative to other therapies! These are only a few of the advances REIMSER prides itself on as they enthusiastically move forward into the future of pharma production.

Vaccine production is now a small portion of RIEMSER’s efforts, but of great interest to our group. We learned that the headquarters of production was in fact the Greifswald location we were visiting. On site, REIMSER  produces a Foot and Mouth Disease vaccine as well as a Swine Fever vaccine. Foot and Mouth Disease and Swine Fever are extremely detrimental viruses on a broad scale, which can severely affect live stock populations across a continent in a short period of time. Thus, the production of these vaccines is of upmost importance to a country’s economy and national security.

Our next speakers served as curators for a wonderful museum of the Friedrich Loeffler institute and RIEMSER lab.  Dr. Sigurd Tesmer, and Dr. Wolfgang Wittmann shared the history of FLI with our group through a plethora of artifacts from the lab’s infancy alongside recollections of the RIEMSER’s successful past. Friedrich Loeffler was the first director of the institute of Hygiene founded in Greifswald,  Germany, in 1888. At one point in his work, Loeffler even worked with the legendary Robert Koch while working in Berlin! Robert Koch is another legendary scientist who is well known for his famous, “ Koch’s Postulates” regarding microbial and disease transmission.

While touring the museum we learned much about Friedrich Loeffler and his influential work with foot and mouth disease. Among his other accomplishments Loeffler also had a mind for public health. Loeffler helped develop a sewer system for the longest street in Greifswald in 1913. Today the very street is named after Loeffler, Friedrich Loeffler Strasse, to commemorate his great contributions. With Loeffler’s passing in 1915, a fellow Veterinarian Otto Waldman, continued Loeffler’s work with the foot and mouth vaccine research. It wasn’t until 1940, that the vaccine was first used on livestock to curb the effects of this dangerous disease. Prof. Wittman explained to us, that at the time the vaccine’s virus content was so low that large quantities were required to be injected to have the appropriate effect, this was sometimes nearly 40-60mls! In order to solve this problem a unique device was made to safely inject this quantity. (Pictured here is that very device! You can see its long tubing and pump like mechanism used to inject the vaccine once a dose was calculated!)

Professor Wittmann showed us some other incredible artifacts during our tour. Some of which included an actual biscuit infused vaccine dose developed at RIEMSER to help curb a hog cholera outbreak in the 90’s. We also viewed a machine designed to give an aerosolized vaccine to an animal, this was groundbreaking for its time.  We were even fortunate enough to see a refurbished desk that Loeffler and colleagues may have once sat at to make these incredible discoveries! Professor Wittmann reminded us that Loeffler will always be remembered for his crucial role in the creation of the first biological institute and important donations to the scientific community.

Before leaving the center we made sure to continue tradition and have our picture taken with the guinea pig statue outside the institute. These three guinea pigs were set here as a reminder to all that pass through the facility, to respect and remember the animals that donate their lives to research. During his studies with foot and mouth disease Loeffler found that guinea pigs were a much more manageable and relevant model than other animal species used in research. Today the statue pays tribute to the animals that have, and continue to donate their lives to save both humans and animals across the globe.

After a short drive we arrived in the beach town of Zinnowitz. Here the students spent time exploring the small shops and walking along the coastline of the Baltic Sea. The Baltic is a body of water bordering Germany, Denmark, Sweden, Finland, Estonia, Latvia, Lithuania, Russia, and Poland. Although the water was quite chilly many of the students enjoyed walking along the expansive beach and having fun in the water! Wading in the water with such an excellent view was a great way to relax before we took our long car ride back to Berlin that evening.

Upon arriving back to Berlin we finished up our long day with dinner at a restaurant in the Center of Berlin’s Nikolai Viertel, Mutter Hoppe. There, many students sampled classic German cuisine! Pictured is an example of a great meal with appetizing German Bloodwurst. This is only one of the nearly 1,500 types of wurst available in Germany! Many students found it rewarding to sample the local wursts after only a few days prior, we’d learned the science and composition behind these great meats! Dinner was always a challenging experience for the students as we tested our abilities to decipher menus and order our meals with the correct pronunciation! We greatly appreciated the help Dr. Hoenig offered, and learned a decent amount of German from the experience!

After our fascinating introduction and tour of the FLI on Monday, we returned to Insel Riems for the privilege of spending the day with a number of the FLI staff, who presented to us on various topics of interest and study at the FLI.  The amount of information we’ve received each day on this trip is truly fantastic, and it’s been incredibly humbling to be in the presence of experts who have shaped the field of veterinary medicine and public health.  Along those lines, we had the once-in-a-lifetime opportunity to attend the inaugural Loeffler Lecture, given by internationally renowned influenza specialist Dr. Ron Fouchier.  This day was full of fascinating information, stimulating discussion, and of course, great food!

Lecture #1: Transmissible Spongiform Encephalopathy (TSE)

Given by: Dr. Anna Buschmann

Dr. Buschmann is the Deputy of the FLI Institute for Novel and Emerging Infectious Diseases, a department that had its beginnings in addressing and responding to TSEs, including Scrapie and BSE (“Mad Cow” Disease).  Since these beginnings, this department has expanded to include many other new and emerging infectious diseases.

Responding to the BSE Crisis: Although the UK is perhaps the most notorious country impacted by the BSE crisis, the whole of Europe was greatly impacted by this disease.  In Germany, greater than 50% of the animals diagnosed were healthy slaughter animals, identified during mandatory screening of carcasses.  The implementation of mandatory screening of cattle above a certain age (72mo for healthy slaughter animals, 48mo for risk animals) was one of the eradication measures implemented early in the crisis, in January 2001. FLI plays an important role in facilitating this measure as the reference laboratory for BSE testing – as such, repeat positives identified at local labs by rapid testing come to FLI for confirmation.

The second measure in responding to the BSE crisis was removal of specified risk materials from the food supply – these include the skull, vertebrae, tonsils, and small intestine.  The only difference in these rules from the United States standards is the removal of the entire small bowel: in the US, only the ileum is removed.  These standards were built upon BSE pathogenesis studies conducted at FLI, which identified Peyer’s patches in the gut as the route of infection in calves.  Interestingly, however, the pathogenesis studies never demonstrated infectivity via the lymphoreticular system – instead, once the prions have been absorbed via Peyer’s patches, they travel via the alimentary nervous system and eventually the splanchnic and vagus nerves to infect the CNS.  These studies also found that in late stage (ie symptomatic) disease, spillover from the CNS could result in the presence of prion protein in peripheral nerves and muscles (until then, it is confined to the CNS).  Frighteningly for those of us who consume red meat in the US, infectivity studies did demonstrate an infective load in the gut outside of the distal ileum.  Infectivity of the tongue has also been called into question, as some cultures consume tongue.  While no PrPsc could be detected in the tongue, the mouse bioassay from this site was in fact positive.

The final measure in Germany’s BSE eradication effort was a ban on the feeding of animal-derived protein and fat to livestock.  Currently, this measure is in debate regarding the feeding of processed animal protein to aquaculture and fish.

Atypical BSE is a current buzz topic in US news, as several cases were recently diagnosed in California.  Dr. Buschmann touched on the pathophysiology of this disease, which differs from the typical form in several ways:

• There are two types of atypical BSE, the H-type and the L-type, depending on the molecular weight of the protein involved
• The anatomical distribution in the brain is different, such that the obex region is not diagnostic.  This has important implications for the rapid testing.
• This form of disease is only seen in older cattle, and is thought to develop spontaneously.
• During pathogenesis studies, animals exposed to infectious doses of atypical BSE prions develop disease faster than expected.

That said, typical and atypical BSE are impossible to differentiate based on clinical picture, and infectivity distribution in the tissues is the same.

In contrast to BSE in cattle, TSEs in small ruminants are detectable in peripheral nerves, lymph nodes, and muscles – this more disseminated distribution represents a greater risk to the consumer.  In small ruminants, BSE cannot be differentiated from scrapie based on clinical signs.  This lecture was the first time I’d heard about atypical Scrapie, which is much less resistant to protein kinase K digestion and may therefore go undetected by rapid tests.  This form of Scrapie heavily affects the cerebellum, and can occur in all sheep, even those of the ARR genotype, which are typically considered resistant to Scrapie.

Lecture #2: Foot and Mouth Disease (FMD)

Given by: Dr. Bernd Haas, Institute of Diagnostic Virology

Given the intimate role of FMD in the founding and history of FLI and Insel Riems, it seems only appropriate that we learn about the current research addressing this disease.  FMD is a very challenging virus in that the seven serotypes, 46 topotypes, and hundreds of sublineages and strains make a universal vaccine impossible.  It is dangerous due to its characteristics such as low infectious dose, high virus excretion and aerosolization, environmental stability, creation of subclinical carriers, and tropisim in a variety species.  In addition, in both pigs and sheep, the peak of viral excretion precedes clinical signs.  FLI studies have determined that pigs excrete about 1000X more virus than cattle.  Other studies at FLI demonstrated that esophageal samples from cattle and sheep showed intermittent shedding of the virus for months to years following infection.

Perhaps the most unique research conducted by FLI regarding FMD is that done in wild boars.  FLI maintains a herd of wild boars for research purposes (pictured below), and has demonstrated that while these animals are highly susceptible to infection with FMD, they remain quite ambulatory despite the presence of lesions on their feet.  Their behavior is so unaffected that diseased animals are difficult to detect until closely examined.  This finding suggests that these wild animals could play an important role in spreading the disease should an outbreak occur in Europe.

Epidemiology of FMD is very different between the developing world and the developed world.  The “red belt” of FMD encompassing North Africa and the Middle East describes regions where FMD is endemic.  In the Eurozone, the current fear of incursion is focused on spread from Turkey or introduction by smuggled feedstuff belonging to refugees from endemic areas.  An outbreak in a developing nation generally follows a typical epidemic curve and control revolves around culling, with the greatest concern being overwhelming of rendering capacity.  The decision regarding whether or not to vaccinate is guided by population density, the availability of a suitable vaccine, and the distribution of the outbreak. FMD must be handled in BSL3+ laboratories, which makes studying this agent quite cumbersome and expensive.

As such, the study and regulations surrounding BSE are a hotbutton political issue.  Testing of vaccines costs millions of Euro, and EU trade restrictions are very strict.  Dr. Haas was refreshingly frank and candid regarding the external factors governing the study of this disease.  This open discussion of political issues and how they impact scientific activities and other aspects of the field is something that seems common to many German academics and professionals – in stark contrast to American classrooms, where elaboration of such issues is often regarded as inappropriate or taboo.  As such, Dr. Haas’ willingness to openly discuss these factors prompted many questions from the students, and a lively discussion of sociological factors governing vaccine use, trade restrictions, and other intersectional issues ensued.

Lecture #3: Schmallenberg Virus

Given by: Dr. Martin Beer, Head of the Institute of Diagnostic Virology

Dr. Beer shared with us the fascinating story behind the discovery of this emerging disease.  Schmallenberg is a disease of ruminants similar to bluetongue, causing fever, decreased milk production, and diarrhea.  Milking robots, which are gaining popularity in Germany, were instrumental in detecting this cluster of clinical signs.  Concerns at the beginning of the outbreak included BHV and Rift Valley Fever, but exhaustive diagnostic evaluation turned up completely negative for known agents.  As such, the hunt for a new agent began.

Metagenomics.  It was a word I had vaguely heard before, but probably couldn’t have defined before this lecture.  Metagenomics refers to the process of analyzing a host sample with new sequencing technology, which utilizes software to distinguish host nucleic acids from pathogen.  This software than uses a server to compare to a database.  Within hours of beginning the metagenomic analysis, a novel Akabane virus had been identified & sequenced, and PCR primers could be developed.  Utilizing this technology, only 2-3 weeks elapsed between first detection and virus isolation – astounding speed when compared with “old” methods of virology.  Interestingly, this virus was only able to replicate on Culicoides cell lines, not any of the mammalian cell lines such as bovine or hamster.  This pointed towards an insect vector.

Meanwhile, the saga of the new disease took a dramatic twist and reared its ugly head in a new way: horrendously malformed lambs were being born to sheep in the affected area.  Up to 50% of lambs on some farms were born with the classical clinical signs: arthrogryphosis, torticollis, and hydrancephaly.   Although the virus has been isolated, the pathogenesis of both the diarrhea and disease in cattle and the malformation in sheep remains unknown.

Thanks to metagenomics, diagnostics such as RT-PCR and a serological assay (neutralization) were rapidly developed.  The virus has spread quickly despite the short viremia, implicating replication within the Culicoides vector.

This lecture was fascinating not only because it provided a real-world introduction to metagenomics, but because it detailed an emerging disease issue in such recent history.  In many of our classes, we are used to hearing about notable outbreaks from the distant past, and seeing the dates from 2011 and 2012 on Dr. Haas’ slides was an unsettling reminder than emerging diseases are a reality of the present and future, not just the past.

Lecture #4: Avian Influenza     

Given by: Dr. Timm Harder, Institute of Diagnostic Virology

FLI boasts the OIE/FAE reference laboratory for Avian Influenza.  As its’ director, Dr. Harder gave us a great overview of the pathobiology and clinical picture of Type A influenza, and proceeded to discuss the issue as it pertains to Germany.  All infections of AI in Germany are the result of introduction by wild birds.  As such, surveillance efforts for HPAI revolve around passive surveillance of wild birds.

Lecture #5: Rabies

Given by: Dr. Thomas Müller

Dr. Müller gave us an informative overview of Rabies with a focus on how the disease burden differs between Europe and the developed world as compared to the developing world.  In the early 1980s, rabies remained widely distributed in Europe, whereas today it has basically disappeared from western Europe.  This eradication success is largely attributable to legislation such as sanitary policy, dog registration, and movement restrictions.

The unfortunate caveat to this success story is that fox rabies has arisen as dog rabies declined.  Conventional “elimination” efforts resulted in decimation of the fox population but were ineffective at controlling the disease.  The problem was most effectively addressed in the 1970s by oral vaccination campaigns.  Switzerland was the first to show field viability of the oral vaccinations.  For an oral vaccination campaign to be successful, large-scale efforts must take place, requiring strong political support.  In the case of fox rabies, Switzerland, Germany, and France became the driving force behind the oral vaccination campaign.  In the current moment, EU support for the ongoing effort remains crucial, and legislation governing pet travel and financing have been integral to its success.

In the developing world, human rabies remains a major problem.  Greater than 90% of human rabies deaths occur in Asia and Africa, and more than half of these occur in children less than 15 years old.  Dog bites account for the overwhelming majority of human rabies deaths, and the great bulk of these occur in rural areas where access to post-exposure prophylaxis is essentially nonexistent.  Dr. Müller attributes the ongoing problem with rabies in certain countries to a “circle of neglect”, and suggested that the key to human rabies control is canine rabies control.

Lecture #6: Pathology Overview and Insel Riems Trivia

Given by: Dr. Jens Peter Teifke

Dr. Teifke capped off our day of lectures at FLI with a whirlwind overview of various animal diseases, pathology, and Insel Riems history.  We learned that the quaint city of Greifswald where we’d been staying boasts one of the oldest universities in Germany and even in Europe, the Ernst Moritz Arndt Universität Greifswald.  We discussed the pathological and clinical findings of Rabbit Hemorrhagic Disease, which provides a good potential model for human hemorrhagic diseases.  We heard about the 2006 H5N1 outbreak in swans near Insel Rügen, which sparked rumors of a biosecurity breach at FLI (these were false, of course).  This grab-bag of applied pathology was an ideal capstone to a day of learning in the Loeffler house!

The First Annual Loeffler Lecture

Topic: The Influenza Virus Riddle – Pandemic Potential or Not?

Presenter: Dr. Ron Fouchier, Erasmus University, Rotterdam

After a brief break to spend some time in downtown Greifswald, a quaint and cobblestoned little square, we attended the First Annual Loeffler Lecture at the Alfried Krupp Wissenschaftskolleg. Dr. Fouchier was named one of Time Magazines 100 Most Influential People this past year for his work studying the evolution of pandemics in humans.  His research team investigates species jumps and tries to predict disease spread, and their recent focus is H5N1 influenza.

Since its first recognition in Hong Kong in199, H5N1 has been documented in numerous countries on three continents.  This virus circulates primarily in poultry but transmission events to mammals, including humans, have been highly lethal.  This begs the question: Could H5N1 cause the next pandemic?

To answer this question, Dr. Fouchier’s research team first determined what the virus would need to acquire for human-to-human transmission:

1. Replication in the upper respiratory tract
2. Replication at high titers
3. Shedding of single particles (to facilitate aerosolization)

His lab demonstrated that when the virus is serially passed between ferrets (the current model for human infection), it naturally acquires adaptation to the upper respiratory tract, easily meeting the first criteria.  When these adapted viruses were sequenced, the researchers discovered that the newly transmissible virus had only undergone five mutations from the wildtype virus to gain this adaptation – all of these occurred in the hemagglutinin protein.  Frighteningly, sequence comparison to circulating strains identified viruses in Japan and Mongolia that only needed three more mutations to acquire this ability.  This points strongly to a pandemic potential for the virus.

Dr. Fouchier’s lab become somewhat notorious when Science imposed a moratorium on the publication of their research, due to fears that in the wrong hands, his research could contribute to manipulation of these viruses by bioterrorists.  When addressing these concerns, Dr. Fouchier pointed out that any one with the tools to study and synthesize these viruses already has the tools to do the work that he did.  Moreover, he made the strong point that the conduction and communication of this work is the only way to advance scientific understanding of this important disease threat.

This talk sparked a lively discussion of research ethics and the principles behind Dr. Fouchier’s work.  Afterwards, Laura, Elizabeth, and I got a great picture with Dr. Fouchier, who is incredibly tall in addition to being incredibly intelligent!

We capped off a brilliant day of lecture and discussion with a fantastic dinner at the Hotel Utkiek.  Everyone enjoyed wonderful seafood dishes while watching the sunset over the Baltic.  Thus ended another truly fantastic day on our journey!