Prevalence of Infection With Dirofilaria Immitis in Cats in Townsville, Australia

Abstract

Objective
Dirofilaria immitis commonly infects Australian dogs. Studies on the prevalence of infection by this parasitic helminth in Australia cats are rare and relatively old. Data obtained from other countries would suggest a likely prevalence of 4.7–16%. The current study aimed to determine the prevalence of D. immitis in an endemic region of Australia by antigen, antibody and PCR testing.

Methods
172 healthy cats over 6 months of age from the Townsville region of Australia were tested for D. immitis specific antibodies and antigen using a commercially available kit. 50 samples were subsequently retested using a second commercially available antibody kit. 48 of these samples were checked for D. immitis DNA using PCR.

Results
No cat tested positive on any test. The Ausvet Epitools epidemiology calculator was used to calculate prevalences. Maximum antigen (1.27%), antibody (2.1%) and PCR (2.1%) prevalences were calculated.

Conclusion
Our results suggest that the prevalence of heartworm infection in pet cats in this region of Australia is lower than expected based on data from other areas around the world.

Full text

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Prevalence of Infection With Dirolaria Immitis in
Cats in Townsville, Australia
Carl Adagra (  cadagra@hotmail.com )
James Cook University College of Medicine and Dentistry https://orcid.org/0000-0001-7120-6151
Richard Squires
James Cook University College of Public Health Medical and Veterinary Sciences
Angela Busst
Wulguru Veterinary Clinic
Jennifer Elliman
James Cook University College of Public Health Medical and Veterinary Sciences
Constantin Constantinoiu
James Cook University College of Public Health Medical and Veterinary Sciences
Research
Keywords: Dirolaria immitis, Australia cats, PCR, DNA
DOI: https://doi.org/10.21203/rs.3.rs-42351/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. 
Read Full License

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Abstract
Objective
Dirolaria immitis
commonly infects Australian dogs. Studies on the prevalence of infection by this
parasitic helminth in Australia cats are rare and relatively old. Data obtained from other countries would
suggest a likely prevalence of 4.7–16%. The current study aimed to determine the prevalence of
D.
immitis
in an endemic region of Australia by antigen, antibody and PCR testing.
Methods
172 healthy cats over 6 months of age from the Townsville region of Australia were tested for
D. immitis
specic antibodies and antigen using a commercially available kit. 50 samples were subsequently
retested using a second commercially available antibody kit. 48 of these samples were checked for
D.
immitis
DNA using PCR.
Results
No cat tested positive on any test. The Ausvet Epitools epidemiology calculator was used to calculate
prevalences. Maximum antigen (1.27%), antibody (2.1%) and PCR (2.1%) prevalences were calculated.
Conclusion
Our results suggest that the prevalence of heartworm infection in pet cats in this region of Australia is
lower than expected based on data from other areas around the world.
Introduction
Dirolariosis (heartworm disease, HWD) is common in dogs in many areas of the world, especially in wet
tropical and subtropical regions1–8.
Dirolaria immitis
is a mosquito-transmitted nematode that can
cause severe cardio-pulmonary pathology and death in canids and other animals 2,9,10. Cats can be
infected but they are less suitable hosts than dogs. Less larvae develop into adults and adult worms have
a shorter lifespan4. Unfortunately, because the pulmonary arteries in cats are smaller than in most dogs,
infections with even a single worm can have fatal consequences and mortality rates are higher in
infected cats than in dogs9,10.
Diagnosis of feline heartworm disease can be challenging. After infection, the arrival and death of worms
within the lungs are thought to stimulate an acute injury. Clinical signs in cats may be absent or
nonspecic such as loss of appetite, lethargy, coughing, dyspnoea and vomiting9. Early radiographic
changes such as bronchointerstitial lung disease, lobar pulmonary arterial enlargement and pulmonary

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hyperination are also non-specic and often subtle11,12. This can lead to the disease being
misdiagnosed as asthma or chronic bronchitis13. Serologic conrmation of feline heartworm disease is
also problematic. Infections typically consist of low numbers of short-lived worms, often of a single sex6.
As routine antigen tests detect what is thought to be a uterine antigen produced only by adult female
worms over 5.6 months of age, they will not detect infection with juveniles or infections involving only
male worms9,14. Another reported cause of false negative tests is the formation of antigen-antibody
complexes that can 'shroud' parasite antigens and prevent their detection by the antigen test kit14,. In
dogs, presence of circulating microlaria can be used to diagnose infections. However, in cats even if
male and female adult worms are both present, microlaria may be only transiently present in blood and
are usually present in low numbers, if at all15. For these reasons, diagnosis of feline heartworm infections
is dicult and often requires a combination of tests15.
The prevalence of infection with
D. immitis
in cats has been reported to be 5–20% of the concurrent
prevalence in the local dog population2–10. However, there are several reasons why revisiting the
prevalence of this worm in Australian cats is warranted. Studies on the prevalence of infection with
D.
immitis
in cats in Australia are rare and relatively old16,17. Australian research indicates that heartworm
infections in cats may be more prevalent than previously thought9. The prevalence of HWD in the world
may also be changing due to the effects of climate change on the geographical range of mosquito
vectors. It has also been reported that lack of ecacy of some heartworm preventative medications in
dogs may potentially be increasing the pool of infected animals, that are then available to be bitten and
transmit the disease to mosquitos in endemic areas18.
The prevalence of infection with
D.immitis
in cats from other endemic regions of the world has been
studied. Based on detection using antibody tests, the prevalence was 4.7% in the Po valley of Northern
Italy, 6.7% in Taiwan, 7.3% in Madrid, 11.47% in Barcelona, 16% in northern Italy and 17% in Florida. The
prevalence using antigen tests are 0.2% in Madrid and 3.1% in Taiwan2–8.
PCR testing for detection of heartworm DNA has been available for more than a decade19–21. PCR is
reported to have a very high sensitivity for
D. immitis
when microlaria are present in the blood19–21. It
was thought that including this test could reveal more information about the rate of feline heartworm
infection.
Materials And Methods
172 blood samples were collected over a 2year period. Samples were only collected from cats that were
over 6months of age, where blood was being collected for unrelated reasons (usually routine health
screens or testing for Feline Immunodeciency Virus). Blood was collected into EDTA and plain tubes.
Plasma from the EDTA tubes was separated by centrifugation antigen/antibody testing. 152 of these
samples were collected from cats from private households where information was available on the cat's
age, heartworm prophylaxis status and access to the outdoors. None of the cats had clinical signs

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suggestive of heartworm infection. Of the 152 cats living in private households, 53.9% were male. 63.9%
had access to the outdoors. 16.4% of cats were on adequate heartworm preventative medications which
was dened as monthly usage of products containing milbemycin oxime, selemectin or imidacloprid and
moxidectin. The mean age of cats tested was 9.8years.
20 samples were taken from cats housed in an animal rescue facility. For these cats information about
age and prior history was not available. These cats had been examined by a veterinarian, considered to
be healthy, and were all estimated to be over 6 months of age.
Initial testing consisted of heartworm antigen and antibody testing using the Bionote Anigen Rapid Feline
Heartworm Antigen/Antibody Test Kit (Bionote Inc. Seoul, Korea), following the manufacturers
instructions. 50 random samples were subsequently retested for heartworm antibodies using Heska Solo
Step antibody test kits(Heska Corporation. Loveland, United States), using the protocol provided with the
kits.
PCR testing was carried out on 48 randomly selected whole blood samples using previously reported
primers for Dirolaria mitochondrial cytochrome oxidase gene, subunit I21. After optimisation of the
nucleic acid extraction and PCR protocols using whole blood from dogs conrmed to be infected using
microscopy, 100ul of whole blood was diluted with 100ul PBS, prior to extraction of genomic DNA using
a QIAmp blood mini kit (Qiagen, Hildon, Germany) with elution into 200ul AE buffer. DNA extracted from
isolated
D. immitis
was used as a positive control. The reaction mixture for the real time PCR was made
up using a Bioline Sensifast SYBR No-ROX mastermix in a total volume of 20ul. The reaction mix
containing 10ul mastermix, 0.3uM of each primer (COXdirHRMF: 5’-AGTATGTTTGTTTGAACTTC- 3’,
COXdirHRMR: 5’-AACGATCCTTATCAGTCAA- 3’) and 2.5ul of DNA. PCR was carried out on a Qiagen
Rotogene 6000 real time PCR machine using the following conditions; 95°C, 3min, followed by 40 cycles
of 95°C, 30s, 52°C, 15s, 72°C, 30s acquiring to the green channel. This was followed by a melt step
using a ramp from 72°C to 95°C with a Hold for 90s on the 1st step and holds for 5s on next steps.
Results
No cats tested positive by any of the tests used.
Antigen / Antibody Detection Tests
Positive control lines were present in all kits used.
PCR
While many samples contained amplication products, examination of the melt curve identied a peak
for the positive control at 80.5°C while all sample positive peaks were at 85.5°C. Sequencing conrmed
the
D. immitis
positive control peak to be
D. immitis
and the sample peak at 85.5°C to be feline genomic
DNA.

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Data analysis
The Ausvet Epitools epidemiology calculator (https://epitools.ausvet.com.au/) was used to calculate
maximum actual prevalence of
D. immitis
with upper 95% condence limits using the following data:
Maximum antigen prevalence using the Bionote Anigen Rapid kit.
Sensitivity was specied as 94.1% based on data provided by the manufacturer. Specicity was
estimated as 99% based on the lack of any positive samples. The maximum actual prevalence was
calculated at 1.27%.
Maximum antibody prevalence using the Bionote Anigen Rapid kit.
Sensitivity and specicity data were not available for the antibody component of the test therefore a
different approach was used to calculate maximum antibody prevalence based on 172 negative samples.
The Townsville cat population was estimated at 50,000 based on data available from Pet Ownership in
Australia, Animal Medicines Australia, the 2016 census and an estimation of the number of stray
animals. Using the equation:
Where
CL = The level of condence.
n = The number of individuals in the sample.
N = The number of individuals in the population.
e = The number of individuals presenting the event in the population that can be detected.
The maximum antibody prevalence was calculated to be less than 13% with a 95% condence limit.
Maximum antibody prevalence using the Heska Solo-Step kit
Sensitivity was specied as 96% and specicity as 98% based on data provided by the manufacturer. The
maximum antibody prevalence was calculated to be less than 2.1%.
PCR

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Sensitivity and specicity of this specic PCR assay is undetermined, but based on prior data a
conservative estimate would be 98% for both sensitivity and specicity. Using this data the maximum
PCR prevalence would be 2.1%.
Discussion
The low prevalence of
D. immitis
infections in cats in this region was unexpected, but supported by a very
low rate of clinically reported feline heartworm cases (Adagra, personal observations). The prevalence of
D. immitis
infection in cats in a particular geographic location is typically much lower than the prevalence
in dogs, but the differences are quite variable by region2–6. This variability is thought to depend on the
variable willingness of local mosquito species to feed on cats versus dogs2–9. When the mosquito
species that are considered to be heartworm vectors in the Townsville region are compared to the
mosquito species that are identied to be natural hosts of
D. immitis
in Florida in the United States, only
one is endemic to both regions; Culex quinquefasciatus22 –24. This species is thought to have a
preference to feed on poultry rather than humans23 and it is quite possible that other feeding preferences
exist. However, there are over 300 species of mosquito present in Australia23 .The role of different species
of mosquito as vectors in HWD in Australia has not been adequately studied and is also liable to change
over time.
Whilst climate change is likely to alter population densities of mosquitos worldwide, human manipulation
of mosquito populations may also alter heartworm prevalences. Recently there was a planned release of
large numbers of
Wolbachia pipientis
-infected Aedes aegypti mosquitos in Townsville25. This
successfully established endemic Wolbachia infection into the local
A. aegypti
population. This led to a
marked decrease in human cases of Dengue fever25. Any effect on heartworm prevalence from such
interventions is unknown.
Wolbachia
is an important symbiote for
D. immitis
, which is usually transmitted
vertically26. Whether
Wolbachia
presence within the mosquitos could aid transmission of
D. immitis
or
possibly enable the worm to use atypical mosquito species as vectors is yet to be researched.
We have estimated the maximum antibody prevalence in cats in this region to be 2.1% and the maximum
antigen and PCR prevalence rates to be 1.27% and 2.1%. The true rates could be lower than this. Not
having a single positive sample raises questions about how low the true prevalence is, as well as the
validity of the diagnostic tests being used. Ideally we would have continued testing cats until we obtained
at least a single positive sample to address these concerns but were unable to do this due to nancial
constraints. The manufacturers of the commercial kits were able to provide data supporting their validity.
We did attempt independently to validate the kits by contacting four feline specialist centres across
eastern Australia to obtain blood from a
D. immitis
infected cat. None had seen a cat that had tested
positive to heartworm infection in recent years which, in itself supports our low prevalence ndings.
Maximum antigen prevalence in this study was calculated at 1.27%. Antigen testing for
D. immitis
in cats
often produces false negative results leading to an articially low maximum prevalence14. Whilst the

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specicity of commercial test kits is good, false negatives can be obtained from infections with juvenile
worms(less than 5.6 months old), infections where only male worms are present, if antigen-antibody
binding occurs and possibly after the administration of heartworm preventatives or doxycycline14.
The phenomenon of antibody-antigen binding has been studied in dogs14. Heat treatment of sera
increases the sensitivity of antigen detection test kits and can resolve discordant results in dogs that are
microlaria positive- but antigen negative14. We opted not to perform heat treatment on our samples.
Heat treatment has been reported to increase the number of false positive results in one study27 and was
not shown to increase the number of positive feline heartworm antigen test results in a second study6.
Theoretically increasing the sensitivity of our test from 94.1–99% would have decreased the calculated
maximum true prevalence only from 1.27–1.21%. However if heat treating sera generated a single false
positive, this would have signicantly increased our calculated maximum true prevalence from 1.27–
2.22%. The use of concurrent PCR testing was intended to help reveal more about any false-negative
results and conrm the species involved, of course no relevant data were obtained.
Climate across the world is usually classied by the Kőppen-Geiger climate classication system which
assigns climate types a code based on seasonal precipitation and temperature patterns28. The climate of
the Townsville region is classied Aw (Tropical savanna climate with dry-winter characteristics)29. Most
regions where heartworm prevalence in cats has been studied are classied Csa or Cfa (Mediterranean
hot summer climate or humid subtropical climate)29. However, Florida (USA) is a location where a large
zone of the Aw climate type can be found, as well as Cfa, Am (Tropical monsoon climate) and Af
(Tropical rainforest climate). In a recent study of HWD prevalence in Florida, animals were recruited from
three locations6. One of these was Miami-Dade county where Aw,Am and Af climate types are found. The
prevalence of HWD was not signicantly different in this county to the more northern locations studied
where only Cfa climate is found.(Jessica Rodriguez, Personal communication). Miami-Dade county is
much wetter than the Townsville region30,31 and we considered the possibility that sparse winter rainfall
could be reducing the number of mosquito vectors and therefore the overall heartworm prevalence in this
region. However, the prevalence of D. immitis in dogs on entry to a local rescue shelter was determined by
conventional antigen testing to be 22.1% (Constantinoiu C. and Coleman, G., personal communication).
This canine HWD rate in the Townsville region would suggest that localised climate conditions are not the
cause for the lack of feline cases in this study.
Our sample population consisted primarily of pet cats. In Florida in 2019, 100 cats from animal shelters
were tested for heartworm antibody, 17% were positive6. However in the same location and year, the
results of 32,067 feline heartworm antibody tests were reported to the Companion Animal Parasite
Council. The overall positive rate was 0.45% (1 in 225 cats)32. The heartworm prophylaxis status of the
cats on which the 32,067 tests were performed is unknown, but presumably the data would be skewed
towards cats that were considered to be on inadequate heartworm prophylaxis. This would suggest that
maybe another factor such as poor nutrition or other parasite burden leads stray cats to be more

Page 8/10
susceptible to developing heartworm antibodies and presumably disease. Of course, we would have
required a much larger sample size to detect a prevalence this low.
The current research has been limited by sample numbers and our lack of positive test results. This
makes it dicult to be condent when calculating the prevalence of HWD. However, the prevalence of
D.
immitis
infection in cats in this study is much lower than expected considering the prevalence in dogs
from this region. The authors still support the routine use of heartworm prophylaxis in Australian cats.
The consequences of infection in this species are severe, if not fatal, with occasional cases still being
reported in the country.
Declarations
Ethics approval and consent to participate.
Advice was sought from the James Cook University Ethics Approval Committee by the authors. We were
advised ethics approval was not required as “waste” blood was used.
Consent for publication
The Authors consent to the publication of this article.
Availability of data and material
Data is available after correspondence with the Authors.
Competing interests
The Authors do not have any competing interests to declare.
Funding
This research was funded by James Cook University and Tropical Qld Cat Clinic Pty Ltd (Owned by Carl
Adagra).
Authors contributions
All authors contributed to the manuscript.
Acknowledgements
The Authors would like to acknowledge Glen Coleman and Jessica Rodriguez who assisted with data on
this project.
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