Diagnostics , Infectious Disease

Diagnostic and Therapeutic Approach: Dogs Infected with Bordetella bronchiseptica and Canine Influenza Virus (H3N8)

Diagnostic and Therapeutic Approach: Dogs Infected with Bordetella bronchiseptica and Canine Influenza Virus (H3N8)
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Laura A. Nafe, DVM, MS, Diplomate ACVIM (Small Animal Internal Medicine)
University of Wisconsin–Madison

Severe cases of kennel cough are highly contagious and can result in life-threatening respiratory compromise. Dr. Nafe provides a detailed discussion, from risk factors to treatment of this disease complex, including managing critically ill dogs.


Bordetella bronchiseptica and canine influenza virus (CIV) are common causes of infectious tracheobronchitis and, occasionally, pneumonia.

Combined, these and other pathogens cause the canine infectious respiratory disease complex (CIRDC), often referred to as kennel cough or infectious tracheobronchitis. The multitude of bacterial and viral organisms associated with CIRDC are listed in Table 1.

In general, morbidity for CIRDC is high with mortality being low. Severe cases can result in life-threatening respiratory compromise due to pneumonia.

Table 1. Bacterial & Viral Pathogens Associated with CIRDC1,2
BACTERIA
  • Bordetella bronchiseptica
  • Mycoplasmas (Mycoplasma cynos)
  • Streptococcus equi (subspecies zooepidemicus)
CANINE VIRUSES
  • Adenovirus 2
  • Bocavirus
  • Coronavirus (pantropic strain)
  • Distemper virus
  • Hepacivirus
  • Herpesvirus
  • Influenza virus
  • Parainfluenza virus
  • Pneumovirus
  • Reovirus
  • Respiratory coronavirus

DISEASE PROFILE

Bordetella bronchiseptica
B bronchiseptica, a primary respiratory pathogen, is a gram-negative, aerobic coccobacillus that is often implicated as a complicating factor in dogs with concurrent viral respiratory infections.1

Virulence Factors. After B bronchiseptica colonizes the airways, it can evade the immune system by expressing various virulence factors that lead to:1,3

  • Direct cellular injury of respiratory epithelium
  • Impaired immune recognition
  • Disrupted immune clearance.

Perhaps one of the most unique and important effects of these virulence factors is the ability to paralyze the mucociliary apparatus—a key component of the respiratory tract’s local defense mechanisms—and create acquired ciliary dysfunction.1,3,4

The mucociliary apparatus moves inhaled debris and opportunistic pathogens away from the lower respiratory tract, decreasing the risk of colonization by these organisms and the potential for associated pneumonia. By paralyzing the cilia, B bronchiseptica not only improves its own virulence and chance for colonization, but also predisposes the patient to opportunistic infections of the lower respiratory tract.1

Disease Spectrum. The spectrum of disease that results from infection with B bronchiseptica is wide, with some dogs manifesting mild disease characterized by nasal discharge and intermittent cough and others developing severe pneumonia that can be life threatening.

Canine Influenza Virus

CIV (H3N8) is most closely related to equine influenza virus, which suggests that a direct transmission from horses to dogs occurred.5 CIV was first detected in racing greyhounds in Florida, and since has become more prevalent among pet dogs, especially those in kennels, shelters, and multidog households.6

Prevalence. The prevalence of serum antibodies against CIV in dogs with no clinical signs of respiratory disease has been shown to be 0.5% to 3%, depending on the risk of the population being evaluated (Figure 1).6 Note that a positive antibody titer in a population of dogs with no signs of respiratory disease likely indicates prior exposure to the virus, rather than active infection.

F03_Fig1

In shelter dogs with signs of respiratory disease, seroprevalence is as high as 50%, depending on length of time since intake to the shelter.7,8 Given the population, these patients are likely co-infected with other common viral and bacterial pathogens that encompass the CIRDC (Table 1).

However, veterinarians should recognize that the prevalence of CIV is much lower in client-owned dogs with respiratory signs, especially if they have not been recently exposed in a shelter or boarding kennel.

Geographic Location. CIV is associated with geographic hot spots, and practitioners should become familiar with the particular areas in which it has been identified. In a recent study, seroprevalence of CIV in dogs with influenza-like illness was highest in the northeast, west, and southwest United States, with the highest representation being in New York, Colorado, and Florida.7

Considerations in Hospital

Considering modes of transmission and environmental survival of the agent is important when discussing management of patients in hospital. Clinicians should take precautions when handling these patients and make efforts to limit exposure throughout the hospital.

  • Hospitalize patients in isolation facilities within the clinic to limit exposure to other dogs, especially those that are immunocompromised. As much as possible, manage infected patients as outpatients.
  • Ensure that staff wear protective clothing, such as gloves and disposable gowns, when working with infectious patients.
  • Keep the veterinary team from handling other patients of the same species during the same shift in which they have handled infectious patients.
  • Limit contact between critical patients that require oxygen therapy and close monitoring—who are not candidates for an isolation area—and other patients in the critical care unit.
  • Implement precautions to limit fomite contamination.

An in-depth review of preventing CIV in the hospital setting is presented in the article Is Your Practice Proactive or Reactive? (January/February 2012), available at tvpjournal.com (Article Library).

RISK FACTORS

Both CIV and B bronchiseptica infections are highly contagious, and dogs of any age and breed may become infected. Those at most risk for exposure and infection include:

  • Dogs housed in boarding facilities, shelters, kennels, and pet shops8,9
  • Puppies, especially those in the above housing situations, due to reduced immunity (both local and systemic), which may result in severe infection and death.9

Factors that contribute to risk and severity of infection in puppies include:

  • Close contact with other dogs and puppies
  • Immature immune systems
  • Immune dysfunction due to concurrent infections (viral, bacterial, parasitic).

Because puppies housed in shelters and pet shops are often in closed ventilation spaces with other puppies from various environments, they are at highest risk.

PREVENTION

Vaccination can help protect against infection and reduce severity of clinical disease. Read Dr. Richard Ford’s article, Kennel Cough Revisited, for a discussion on current advances in vaccination for canine respiratory disease.

TRANSMISSION

Mode of Transmission

Transmission of B bronchiseptica and CIV occurs via:1

  • Oronasal contact with other dogs, caregivers, or fomites
  • Inhalation of aerosolized microdroplets of respiratory secretions.

In high-density housing situations, direct contact among dogs is most common. Less commonly, fomites serve as a source of transmission.

Shedding & Survival

Most viruses begin shedding within 2 days post infection, and may continue to shed for 6 to 10 days before viral load decreases.5 B bronchiseptica can survive in the environment for extended periods of time,1 and can be shed from dogs that appear healthy because it has the ability to elude the immune system for weeks to months.

INITIAL DIAGNOSIS

Although definitive diagnosis is pursued in some cases, a suspected clinical diagnosis can often be made based on:

  • Clinical signs
  • Assessment of risk/exposure
  • Response to appropriate treatment.

Clinical Presentation

Clinical presentation varies among individual cases of B bronchiseptica and CIV infections, based on severity and concurrent bacterial and/or viral pathogens involved. Clinical signs include:

  • Acute onset of a nonproductive cough (most common clinical sign)
  • Serous or mucopurulent nasal and/or ocular discharge
  • Sneezing
  • Tachypnea, respiratory distress, systemic illness, and fever (more severe cases).

Thoracic Radiographs

Thoracic radiographs may support a diagnosis of B bronchiseptica or CIV (Table 2) but, more important, help to rule out other causes of acute cough.
Thoracic radiographs are recommended for any patient with:

  • Persistent (> 1–2 weeks) or worsening cough
  • Respiratory distress
  • Signs of systemic illness (eg, lethargy, decreased appetite).

In more severe cases, radiographs are necessary to evaluate if pneumonia is present.

Thoracic radiographs are not typically indicated in otherwise healthy patients with acute onset of only coughing (no signs of respiratory distress, tachypnea, fever, or systemic illness).

F03_Fig2

Laboratory Analysis

In complicated cases, a complete blood count and serum biochemical profile should be performed to assess systemic health, but these diagnostics are not generally necessary for diagnosis of B bronchiseptica or CIV.

DEFINITIVE DIAGNOSIS

Bordetella bronchiseptica

Definitive diagnosis of B bronchiseptica is based on isolation of the pathogen from aerobic culture of respiratory secretions.

Sample Collection. For cytology and culture of bacteria, obtain airway samples via:

  • Transtracheal or endotracheal wash
  • Bronchoalveolar lavage (blind or bronchoscopy-guided).

Patients with unresponsive focal pneumonia may require bronchoscopy-guided bronchoalveolar lavage fluid collection to obtain a sample that accurately represents the causative pathogen.

Nasal, oral, oropharyngeal, and nasopharyngeal bacterial cultures are not recommended, as they yield growth of normal respiratory flora, making it difficult to determine the primary pathogen causing disease. In addition, deep oral swabs are not recommended in puppies with community-acquired pneumonia.10

Mycoplasma species cannot be seen on cytology and are difficult to culture; consider submitting a mycoplasma polymerase chain reaction (PCR) or mycoplasma culture, when indicated.

Sample Preparation. Following collection of an airway sample, cytology should be performed as quickly as possible (ideally within hours) to reduce disruption of the cells.11,12Because many samples are fairly low in cellularity, a concentrated population of representative cells can be evaluated by a cytospin or line smear preparation or manual smearing of pelleted cells.

If the clinician is planning to send the sample to a clinical pathologist for evaluation, the sample should be stored at 4°C and shipped overnight (ideally processed within 24 hours after collection).12

Sample Evaluation. Evaluate the sample for the differential cell count and presence of bacteria or other infectious organisms. B bronchiseptica has a characteristic cytologic appearance, with the coccobacilli adhering to respiratory epithelial cells (Figure 3).

F03_Fig3

Canine Influenza Virus

Definitive diagnosis of CIV is based on real-time PCR (RT-PCR) identification of CIV from respiratory secretions. RT-PCR (nasal or pharyngeal swabs) has replaced viral isolation via tissue culture or serology due to:13,14

  • Difficulty in obtaining samples for culture antemortem
  • Concerns about previous exposure clouding results of serologic testing.

Definitive diagnosis is a challenge in some patients because viral shedding declines within approximately 7 to 10 days post exposure, often prior to onset of clinical signs, resulting in a false–negative RT-PCR.5

ANTIMICROBIAL THERAPY

Antimicrobial therapy can be important in patients with suspected B bronchiseptica infections or, if CIV or another viral respiratory pathogen is suspected, to treat secondary bacterial infections.

Doxycycline

Doxycycline (5 mg/kg PO Q 12 H or 10 mg/kg PO Q 24 H) is my treatment of choice for B bronchiseptica and most infectious respiratory diseases.

Enamel Discoloration. Clinicians are often concerned about using doxycycline in young patients due to its potential to discolor enamel of developing teeth; however, it is less likely to cause discoloration compared to other tetracycline antibiotics. Limiting treatment to < 10 days further reduces the risk.1

Doxycycline Resistance. Some isolates of B bronchiseptica are doxycycline-resistant, and patients may require treatment with a fluoroquinolone (enrofloxacin or marbofloxacin), azithromycin, or chloramphenicol; however, management of these patients should ideally be based on culture and susceptibility of airway samples.

Other Tetracyclines

The current shortage of doxycycline has dramatically increased its cost; therefore, it is a less desirable option for owners with financial concerns. Most clinicians are using other tetracycline drugs, such as minocycline, in place of doxycycline for treatment of tick-borne disease, but the pharmacokinetics of minocycline for various disease conditions in dogs is currently under investigation.15

Dosing for treatment of bordetellosis is currently unknown; recommended treatment of methicillin-resistant staphylococcal infections is 5 mg/kg PO Q 12 H or 10 mg/kg PO Q 24 H.

Other Antibiotics

Other antibiotics to consider include:

  • Azithromycin
  • Fluoroquinolones
  • Amoxicillin-clavulanate
  • Cephalosporins.

Note that tetracyclines and fluoroquinolones readily cross the blood–bronchus barrier, but penicillins and cephalosporins do not and, therefore, may be associated with treatment failure in some cases. Although fluoroquinolones are less desirable in young animals due to their effects on cartilage development, this risk may be of less concern in patients with life-threatening infections.16

MANAGING CRITICALLY ILL DOGS

When managing critically ill dogs with B bronchiseptica and/or CIV, implement the following supportive therapy:

1. Provide Increased Oxygen Concentrations
Severe cases of B bronchiseptica and CIV may present in respiratory distress and require oxygen supplementation.Assess oxygenation via pulse oximetry and/or arterial blood gas analysis. Pulse oximetry is noninvasive and available in most practices, but does not always provide an accurate measurement.Provide oxygen supplementation to patients with an:

  • SpO2 of < 92% to 94% or PaO2 < 80 mm Hg, especially if signs of respiratory difficulty are present
  • Increase in respiratory effort, even if the patient is oxygenating appropriately.

Common methods of oxygen supplementation in hospital include oxygen cage, tent, nasal cannula(s), and nasal prongs. Nasal cannula or prongs may work best for highly contagious patients that must be isolated, but require supervision to ensure the catheter does not become dislodged (Figure 4).

f03_fig04

2. Improve Clearance of Respiratory Secretions
Critical patients often lose fluids through the respiratory tract, especially if they are febrile, leading to increased viscosity of secretions and reduced ciliary clearance. Initiate IV fluids to replace fluids lost and improve clearance of respiratory secretions.

Nebulization with sterile saline (6–10 mL) results in a liquid particulate suspension that improves clearance of tracheal and bronchial secretions. Nebulization followed by coupage may be performed for 15 to 20 minutes every 4 to 8 hours in hospitalized patients; owners may rent or purchase a handheld jet nebulizer for use at home.

3. Treat Primary or Secondary Bacterial Pathogens
Antibiotic therapy is essentially the same for all patients (see ANTIMICROBIAL THERAPY); however, injectable antibiotics should be considered for critically ill patients, due to associated gastrointestinal upset and poor bioavailability of oral antibiotics in anorexic patients. Fluoroquinolones (enrofloxacin, ciprofloxacin) may be preferred for injection because, compared to doxycycline, they provide more broad spectrum coverage for gram-negative organisms, are unlikely to result in phlebitis, and are less expensive.

ADDITIONAL THERAPIES

Glucocorticoids & Cough Suppressants

Anti-inflammatory glucocorticoids and/or cough suppressants may be indicated for patients with infectious tracheobronchitis or suspected tracheitis secondary to frequent coughing. Ensure the patient has no evidence of pneumonia and is otherwise systemically healthy before intervening with these therapies.

Most patients with CIRDC do not require these therapies, and I do not recommend using oral/inhaled corticosteroids or cough suppressants in patients with moderate to severe B bronchiseptica infection or CIV, especially if pneumonia has developed.

Cough suppressants, in particular, are contraindicated in patients with bronchopneumonia, as suppression of cough can prevent clearance of bacteria, worsen disease, and/or delay recovery.

Bronchodilators

Methylxanthines (eg, theophylline, aminophylline) and beta-2 agonists are bronchodilators that prevent bronchospasm. There is evidence that methylxanthines improve ventilation and diaphragmatic contractility in dogs, which may result in improved PaCO2 levels in severely affected puppies; however, there is no evidence of benefit in patients with uncomplicated CIRDC.17

If considering use of a bronchodilator in a patient with CIRDC, I prefer methlyxanthines due to their other potentially beneficial effects, including anti-inflammatory properties, improved mucociliary clearance, and improved diaphragmatic contractility.17 Unlike cats and humans, dogs do not develop true smooth muscle bronchoconstriction, and therefore, beta-2-agonists are not useful in the management of canine respiratory disease.

In my opinion, bronchodilator therapy, while extremely important in management of feline lower airway disease, has limited value in canine respiratory disease and may have undesirable adverse effects (cardiac, gastrointestinal). Therefore, I do not recommend bronchodilators for treatment of infectious tracheobronchitis or pneumonia caused by B bronchiseptica or CIV.

Expectorants

Aerosolized or oral expectorant or mucolytic therapy is often instituted in cases of canine respiratory diseases that result in excessive tracheal and/or bronchial secretions.

However, I do not recommend therapy with expectorants because:

  • Nebulized N-acetylcysteine can be irritating and result in bronchospasm, further worsening tracheobronchitis and coughing.
  • Guaifenesin, an expectorant often paired with a cough suppressant, has no scientific or anecdotal (that I have observed) evidence supporting its use in patients with B bronchiseptica or CIV.

Antiviral Agents

The safety and efficacy of specific antiviral agents, such as neuroaminidase inhibitors (eg, oseltamivir phosphate, zanaminir) has not been evaluated in dogs.1 Therefore, these agentscannot be recommended for dogs with CIV or other respiratory viral diseases.

Intranasal Vaccines

There are anecdotal reports promoting administration of the intranasal B bronchiseptica vaccine in dogs with CIRDC. However, to date, there are no controlled studies that support its use as a “therapeutic” intervention in dogs with B bronchiseptica infection or CIV and, in critical patients with this infection or virus, intranasal vaccine administration may worsen the course of disease because the immune system is already compromised, and an immune response places additional stress on the system.

CIRDC = canine infectious respiratory disease complex; CIV = canine influenza virus; PaCO2 = arterial partial pressure of carbon dioxide; PaO2 = arterial partial pressure of oxygen; PCR = polymerase chain reaction; RT-PCR = real-time PCR; SpO2 = hemoglobin oxygenation saturation measured by pulse oximetry

References

  1. Ford RB. Canine infectious tracheobronchitis. In Greene CE (ed): Infectious Diseases of the Dog and Cat, 4th ed. St. Louis: Saunders, 2012, pp. 55-65.
  2. Priestnall SL, Mitchell JA, Walker CA, et al. New and emerging pathogens in canine infectious respiratory disease. Vet Pathol 2013 [Epub ahead of print].
  3. Mattoo S, Cherry JD. Molecular pathogenesis, epidemiology, and clinical manifestation of respiratory infections due to Bordetella pertussis and other Bordetella subspecies. Clin Microbiol Rev 2005; 18:326-382.
  4. Anderton TI, Maskell DJ, Preston A. Ciliostasis is a key early event during colonization of canine tracheal tissue by Bordetella bronchiseptica. Microbiol 2004; 150:2843-2855.
  5. Crawford PC, Dubovi EJ, Castleman WL, et al. Transmission of equine influenza virus to dogs. Science 2005; 310:482-485.
  6. Serra VF, Stanzani G, Smith G, et al. Point seroprevelence of canine influenza virus H3N8 in dogs participating in a flyball tournament in Pennsylvania. JAVMA 2011; 238:726-730.
  7. Anderson TC, Crawford PC, Dubovi EJ, et al. Prevalence of and exposure factors for seropositivity to H3N8 canine influenza virus in dogs with influenza-like illness in the United States. JAVMA 2013; 242:209-216.
  8. Holt DE, Mover MR, Brown DC. Serologic prevalence of antibodies against canine influenza virus (H3N8) in dogs in a metropolitan animal shelter. JAVMA 2010; 237:71-73.
  9. Radhakrishnan A, Drobatz KJ, Culp WT, et al. Community-acquired infectious pneumonia in puppies: 65 cases (1993-2002). JAVMA 2007; 230:1493-1497.
  10. Sumner CM, Rozanski EA, Sharp CR, et al. The use of deep oral swabs as a surrogate for transoral tracheal wash to obtain bacterial cultures in dogs with pneumonia. J Vet Emerg Crit Care 2011; 21:515-520.
  11. Dehard S, Bernaerts F, Peeters D, et al. Comparison of bronchoalveolar lavage cytospins and smears in dogs and cats. JAAHA 2008; 44:285-294.
  12. Nafe LA, DeClue AE, Reinero CR. Storage alters feline bronchoalveolar lavage fluid cytological analysis. J Feline Med Surg 2011; 13:94-100.
  13. Anderson TC, Crawford PC, Katz JM, et al. Diagnostic performance of the canine influenza A virus subtype H3N8 hemagglutination inhibition assay. J Vet Diagn Invest 2012; 24:499-508.
  14. Pecoraro HL, Spindel ME, Bennett S, et al. Evaluation of virus isolation, one-step real-time reverse transcription polymerase chain reaction assay, and two rapid influenza diagnostic tests for detecting canine Influenza A virus H3N8 shedding in dogs. J Vet Diagn Invest 2013; 25:402-406.
  15. Maaland MG, Guardabassi L, Papich MG. Minocycline pharmacokinetics and pharmacodynamics in dogs: Dosage recommendations for treatment of methicillin-resistant Staphylococcus pseudintermedius infections. Vet Dermatol 2014; 25:182-190.
  16. Lim S, Hossain MA, Park J, et al. The effects of enrofloxacin on canine tendon cells and chondrocytes proliferation in vitro. Vet Res Commun 2008; 32:243-253.
  17. Jagers JV, Hawes HG, Easton PA. Aminophylline increases ventilation and diaphragm contractility in awake canines. Respir Physiol Neurobiol 2009; 167:273-280.
F03_BLaura A. Nafe, DVM, MS, Diplomate ACVIM (Small Animal Internal Medicine), is a clinical instructor in small animal internal medicine at University of Wisconsin SVM–Madison. She received her DVM from University of Missouri then completed an internship in small animal medicine and surgery at North Carolina State University, before completing a residency in small animal internal medicine at University of Missouri.
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aria-required="true"/> <label for='input_6_10_1' id='input_6_10_1_label' >Street Address</label> </span><span class='ginput_full address_line_2' id='input_6_10_2_container' > <input type='text' name='input_10.2' id='input_6_10_2' value='' /> <label for='input_6_10_2' id='input_6_10_2_label' >Address Line 2</label> </span><span class='ginput_left address_city' id='input_6_10_3_container' > <input type='text' name='input_10.3' id='input_6_10_3' value='' aria-required="true"/> <label for='input_6_10_3' id='input_6_10_3_label' >City</label> </span><span class='ginput_right address_state' id='input_6_10_4_container' > <input type='text' name='input_10.4' id='input_6_10_4' value='' aria-required="true"/> <label for='input_6_10_4' id='input_6_10_4_label' >State / Province / Region</label> </span><span class='ginput_left address_zip' id='input_6_10_5_container' > <input type='text' name='input_10.5' id='input_6_10_5' value='' aria-required="true"/> <label for='input_6_10_5' id='input_6_10_5_label' >ZIP / Postal Code</label> </span><span class='ginput_right address_country' id='input_6_10_6_container' > <select name='input_10.6' id='input_6_10_6' aria-required="true"><option value='' selected='selected'></option><option value='Afghanistan' >Afghanistan</option><option value='Åland Islands' >Åland Islands</option><option value='Albania' >Albania</option><option value='Algeria' >Algeria</option><option value='American Samoa' >American Samoa</option><option value='Andorra' >Andorra</option><option value='Angola' >Angola</option><option value='Anguilla' >Anguilla</option><option value='Antarctica' >Antarctica</option><option value='Antigua and Barbuda' >Antigua and Barbuda</option><option value='Argentina' >Argentina</option><option value='Armenia' >Armenia</option><option value='Aruba' >Aruba</option><option value='Australia' >Australia</option><option value='Austria' >Austria</option><option value='Azerbaijan' >Azerbaijan</option><option value='Bahamas' >Bahamas</option><option value='Bahrain' >Bahrain</option><option value='Bangladesh' >Bangladesh</option><option value='Barbados' >Barbados</option><option value='Belarus' >Belarus</option><option value='Belgium' >Belgium</option><option value='Belize' >Belize</option><option value='Benin' >Benin</option><option value='Bermuda' >Bermuda</option><option value='Bhutan' >Bhutan</option><option value='Bolivia' >Bolivia</option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba</option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina</option><option value='Botswana' >Botswana</option><option value='Bouvet Island' >Bouvet Island</option><option value='Brazil' >Brazil</option><option value='British Indian Ocean Territory' >British Indian Ocean Territory</option><option value='Brunei Darussalam' >Brunei Darussalam</option><option value='Bulgaria' >Bulgaria</option><option value='Burkina Faso' >Burkina Faso</option><option value='Burundi' >Burundi</option><option value='Cambodia' >Cambodia</option><option value='Cameroon' >Cameroon</option><option value='Canada' >Canada</option><option value='Cape Verde' >Cape Verde</option><option value='Cayman Islands' >Cayman Islands</option><option value='Central African Republic' >Central African Republic</option><option value='Chad' >Chad</option><option value='Chile' >Chile</option><option value='China' >China</option><option value='Christmas Island' >Christmas Island</option><option value='Cocos Islands' >Cocos Islands</option><option value='Colombia' >Colombia</option><option value='Comoros' >Comoros</option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the</option><option value='Congo, Republic of the' >Congo, Republic of the</option><option value='Cook Islands' >Cook Islands</option><option value='Costa Rica' >Costa Rica</option><option value='Côte d&#039;Ivoire' >Côte d&#039;Ivoire</option><option value='Croatia' >Croatia</option><option value='Cuba' >Cuba</option><option value='Curaçao' >Curaçao</option><option value='Cyprus' >Cyprus</option><option value='Czech Republic' >Czech Republic</option><option value='Denmark' >Denmark</option><option value='Djibouti' >Djibouti</option><option value='Dominica' >Dominica</option><option value='Dominican Republic' >Dominican Republic</option><option value='Ecuador' >Ecuador</option><option value='Egypt' >Egypt</option><option value='El Salvador' >El Salvador</option><option value='Equatorial Guinea' >Equatorial Guinea</option><option value='Eritrea' >Eritrea</option><option value='Estonia' >Estonia</option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)</option><option value='Ethiopia' >Ethiopia</option><option value='Falkland Islands' >Falkland Islands</option><option value='Faroe Islands' >Faroe Islands</option><option value='Fiji' >Fiji</option><option value='Finland' >Finland</option><option value='France' >France</option><option value='French Guiana' >French Guiana</option><option value='French Polynesia' >French Polynesia</option><option value='French Southern Territories' >French Southern Territories</option><option value='Gabon' >Gabon</option><option value='Gambia' >Gambia</option><option value='Georgia' >Georgia</option><option value='Germany' >Germany</option><option value='Ghana' >Ghana</option><option value='Gibraltar' >Gibraltar</option><option value='Greece' >Greece</option><option value='Greenland' >Greenland</option><option value='Grenada' >Grenada</option><option value='Guadeloupe' >Guadeloupe</option><option value='Guam' >Guam</option><option value='Guatemala' >Guatemala</option><option value='Guernsey' >Guernsey</option><option value='Guinea' >Guinea</option><option value='Guinea-Bissau' >Guinea-Bissau</option><option value='Guyana' >Guyana</option><option value='Haiti' >Haiti</option><option value='Heard and McDonald Islands' >Heard and McDonald Islands</option><option value='Holy See' >Holy See</option><option value='Honduras' >Honduras</option><option value='Hong Kong' >Hong Kong</option><option value='Hungary' >Hungary</option><option value='Iceland' >Iceland</option><option value='India' >India</option><option value='Indonesia' >Indonesia</option><option value='Iran' >Iran</option><option value='Iraq' >Iraq</option><option value='Ireland' >Ireland</option><option value='Isle of Man' >Isle of Man</option><option value='Israel' >Israel</option><option value='Italy' >Italy</option><option value='Jamaica' >Jamaica</option><option value='Japan' >Japan</option><option value='Jersey' >Jersey</option><option value='Jordan' >Jordan</option><option value='Kazakhstan' >Kazakhstan</option><option value='Kenya' >Kenya</option><option value='Kiribati' >Kiribati</option><option value='Kuwait' >Kuwait</option><option value='Kyrgyzstan' >Kyrgyzstan</option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic</option><option value='Latvia' >Latvia</option><option value='Lebanon' >Lebanon</option><option value='Lesotho' >Lesotho</option><option value='Liberia' >Liberia</option><option value='Libya' >Libya</option><option value='Liechtenstein' >Liechtenstein</option><option value='Lithuania' >Lithuania</option><option value='Luxembourg' >Luxembourg</option><option value='Macau' >Macau</option><option value='Macedonia' >Macedonia</option><option value='Madagascar' >Madagascar</option><option value='Malawi' >Malawi</option><option value='Malaysia' >Malaysia</option><option value='Maldives' >Maldives</option><option value='Mali' >Mali</option><option value='Malta' >Malta</option><option value='Marshall Islands' >Marshall Islands</option><option value='Martinique' >Martinique</option><option value='Mauritania' >Mauritania</option><option value='Mauritius' >Mauritius</option><option value='Mayotte' >Mayotte</option><option value='Mexico' >Mexico</option><option value='Micronesia' >Micronesia</option><option value='Moldova' >Moldova</option><option value='Monaco' >Monaco</option><option value='Mongolia' >Mongolia</option><option value='Montenegro' >Montenegro</option><option value='Montserrat' >Montserrat</option><option value='Morocco' >Morocco</option><option value='Mozambique' >Mozambique</option><option value='Myanmar' >Myanmar</option><option value='Namibia' >Namibia</option><option value='Nauru' >Nauru</option><option value='Nepal' >Nepal</option><option value='Netherlands' >Netherlands</option><option value='New Caledonia' >New Caledonia</option><option value='New Zealand' >New Zealand</option><option value='Nicaragua' >Nicaragua</option><option value='Niger' >Niger</option><option value='Nigeria' >Nigeria</option><option value='Niue' >Niue</option><option value='Norfolk Island' >Norfolk Island</option><option value='North Korea' >North Korea</option><option value='Northern Mariana Islands' >Northern Mariana Islands</option><option value='Norway' >Norway</option><option value='Oman' >Oman</option><option value='Pakistan' >Pakistan</option><option value='Palau' >Palau</option><option value='Palestine, State of' >Palestine, State of</option><option value='Panama' >Panama</option><option value='Papua New Guinea' >Papua New Guinea</option><option value='Paraguay' >Paraguay</option><option value='Peru' >Peru</option><option value='Philippines' >Philippines</option><option value='Pitcairn' >Pitcairn</option><option value='Poland' >Poland</option><option value='Portugal' >Portugal</option><option value='Puerto Rico' >Puerto Rico</option><option value='Qatar' >Qatar</option><option value='Réunion' >Réunion</option><option value='Romania' >Romania</option><option value='Russia' >Russia</option><option value='Rwanda' >Rwanda</option><option value='Saint Barthélemy' >Saint Barthélemy</option><option value='Saint Helena' >Saint Helena</option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis</option><option value='Saint Lucia' >Saint Lucia</option><option value='Saint Martin' >Saint Martin</option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon</option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines</option><option value='Samoa' >Samoa</option><option value='San Marino' >San Marino</option><option value='Sao Tome and Principe' >Sao Tome and Principe</option><option value='Saudi Arabia' >Saudi Arabia</option><option value='Senegal' >Senegal</option><option value='Serbia' >Serbia</option><option value='Seychelles' >Seychelles</option><option value='Sierra Leone' >Sierra Leone</option><option value='Singapore' >Singapore</option><option value='Sint Maarten' >Sint Maarten</option><option value='Slovakia' >Slovakia</option><option value='Slovenia' >Slovenia</option><option value='Solomon Islands' >Solomon Islands</option><option value='Somalia' >Somalia</option><option value='South Africa' >South Africa</option><option value='South Georgia' >South Georgia</option><option value='South Korea' >South Korea</option><option value='South Sudan' >South Sudan</option><option value='Spain' >Spain</option><option value='Sri Lanka' >Sri Lanka</option><option value='Sudan' >Sudan</option><option value='Suriname' >Suriname</option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands</option><option value='Sweden' >Sweden</option><option value='Switzerland' >Switzerland</option><option value='Syria' >Syria</option><option value='Taiwan' >Taiwan</option><option value='Tajikistan' >Tajikistan</option><option value='Tanzania' >Tanzania</option><option value='Thailand' >Thailand</option><option value='Timor-Leste' >Timor-Leste</option><option value='Togo' >Togo</option><option value='Tokelau' >Tokelau</option><option value='Tonga' >Tonga</option><option value='Trinidad and Tobago' >Trinidad and Tobago</option><option value='Tunisia' >Tunisia</option><option value='Turkey' >Turkey</option><option value='Turkmenistan' >Turkmenistan</option><option value='Turks and Caicos Islands' >Turks and Caicos Islands</option><option value='Tuvalu' >Tuvalu</option><option value='Uganda' >Uganda</option><option value='Ukraine' >Ukraine</option><option value='United Arab Emirates' >United Arab Emirates</option><option value='United Kingdom' >United Kingdom</option><option value='United States' >United States</option><option value='Uruguay' >Uruguay</option><option value='US Minor Outlying Islands' >US Minor Outlying Islands</option><option value='Uzbekistan' >Uzbekistan</option><option value='Vanuatu' >Vanuatu</option><option value='Venezuela' >Venezuela</option><option value='Vietnam' >Vietnam</option><option value='Virgin Islands, British' >Virgin Islands, British</option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.</option><option value='Wallis and Futuna' >Wallis and Futuna</option><option value='Western Sahara' >Western Sahara</option><option value='Yemen' >Yemen</option><option value='Zambia' >Zambia</option><option value='Zimbabwe' 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