Parasitology , Practical Parasitology

Feline Arthropods

Feline Arthropods
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Lindsay Starkey, DVM, Oklahoma State University, and Jay Stewart, DVM, Aumsville Animal Clinic, Aumsville, Oregon

The mission of the Companion Animal Parasite Council (CAPC) is to foster animal and human health, while preserving the human—animal bond, through recommendations for the diagnosis, treatment, prevention, and control of parasitic infections. For more information, including detailed parasite control recommendations, please visit capcvet.org.

Ectoparasites—in addition to being a nuisance—are associated with allergies, skin infections, and self-induced traumatic injury in pets. They are also vectors of infectious and zoonotic disease-causing agents, some of which can prove fatal.1-6 Fleas, ticks, mites, and lice are common ectoparasites seen on cats in the United States.

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FIGURE 1. Adult Ctenocephalides felis. Courtesy National Center for Veterinary Parasitology, Oklahoma State University

FLEAS

The most common ectoparasite that infests cats (and dogs) in North America is the cat flea, Ctenocephalides felis (Figure 1). Other fleas also infest cats, including Echidnophaga gallinacea, Pulex irritans, and P simulans.1,7,8

Life Cycle

Fleas have 4 life stages:

  1. Eggs are deposited by fed females and quickly fall into the environment; a female flea produces 40 to 50 eggs per day.9
  2. Larvae hatch from eggs in 1 to 6 days.1
    • Food sources include organic debris (flea eggshells, adult flea feces) and other larval fleas.1
    • Larvae develop in areas away from direct sunlight, including cool, shady areas outdoors, such as under porches or decks, and indoor locations, including carpet, furniture, and baseboards.1,4
  3. Pupae develop from mature larvae.1
    • Adults emerge from pupal casings in as little as 2 weeks or up to 6 months.1,10,11
    • Emergence is stimulated by mechanical pressure, carbon dioxide, and increased temperature.10
  4. Adults quickly find a host after emerging, and begin feeding within minutes.1
    • Egg production begins around 24 hours after initiation of feeding.1
    • Adults account for only about 5% of the total flea population in an infestation.12

Completion of the life cycle typically takes 3 to 8 weeks, and depends on relative humidity and temperature; a moist, warm environment is ideal.4

Significance of Infestation

Fleas can cause irritation and pruritus, and certain cats may develop flea allergy dermatitis. Heavy infestations can lead to anemia and, if not managed appropriately, can be fatal.1

Fleas are also important vectors of disease-causing agents. They can transmit Dipylidium caninum and bacteria that cause bartonellosis, hemotropic mycoplasmosis, rickettsiosis, plague, and tularemia; many of the aforementioned agents can infect humans as well.5,6

Treatment Strategies

Eliminating flea infestations can be challenging, and many factors must be considered:12-14

  • Killing the fleas on the patient
  • Eliminating eggs, larvae, and pupae in the environment; as these life stages mature, they will continue to infest the pet
  • Identifying additional untreated pets, feral animals, or peri-domestic wildlife that contribute to environmental contamination
  • Choosing products that address difficult-to-treat life stages: Larvae and eggs may be located in hard-to-reach areas (eg, deep within the carpet) and pupae can withstand many chemical treatments.

Note that

many drugs are formulated to treat ectoparasites, but some that are safe for use in or on dogs are not safe for use in cats due to potential adverse effects, including death. Follow label instructions carefully.

 

Implementation of an integrated pest management strategy is often necessary to resolve flea infestation:4,13

  1. Routinely apply approved, persistent flea-control products to every pet in the home year-round (Table 1):15
    • Insecticides to kill the adult fleas
    • Insect growth regulators and insect development inhibitors, which prevent maturation of immature flea stages
  2. Treat the environment:4,14
    • Mechanically remove immature stages by laundering flea-contaminated items and frequently vacuuming
    • Apply premise sprays to accelerate death of some immature flea stages in the environment
    • Address sources of continued environmental contamination.

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TICKS
Ticks, although more common on dogs, can infest cats as well.16 The most common ticks found on cats in the U.S. are Amblyomma americanum, Dermacentor variabilis, Ixodes scapularis, and Otobius megnini (Figure 2); however, other tick species, such as Rhipicephalus sanguineus, occasionally infest cats.4,16-18

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FIGURE 2. Larva, nymph, and adults of Amblyomma americanum (A); adults of Dermacentor variabilis (B) and Ixodes scapularis (C); and a nymph of Otobius megnini (D). Courtesy National Center for Veterinary Parasitology, Oklahoma State University

Life Cycle

Life cycles differ greatly between hard and soft ticks. For hard ticks—A americanum, D variabilis, and I scapularis—3 different hosts are required to complete the life cycle:19

  1. A blood-engorged female deposits a single clutch of thousands of eggs into the environment; from those eggs hatch 6-legged larvae that find the first host.
  2. Larvae attach and feed for a few days before falling off and molting in the environment into 8-legged nymphs. Nymphs find another host, feed for days to a week, detach, and fall into the environment, molting to the final stage—8-legged adult male and female ticks.
  3. Adult ticks find hosts and feed for 1 to 2 weeks; engorged, mated females detach before laying their egg clutch.23

For the soft tick—O megnini—only one host is required to complete its life cycle:18

  1. The female can lay several clutches of eggs in the environment.
  2. When the larvae hatch, they obtain a host, crawling into the ear canal, feeding, and molting into the first and second nymphal stages.
  3. Second-stage nymphs crawl out of the ear canal and enter the environment, molting into the nonparasitic adult stage; the adults mate off-host.

Geographic distribution and host preferences differ among tick species (Table 2).18-22

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Significance of Infestation

As seen with flea infestations, ticks are associated with irritation, pruritus, anemia, and potential secondary bacterial skin infections; furthermore, due to the attachment and feeding practices of most ticks, severe skin reactions at the bite site can occur.4,16-18,21

  • O megnini exclusively infests the ears, resulting in inflammation of the ear canal.23
  • Attachment of D variabilis has been associated with a paralytic condition that resolves upon tick removal.18

Ticks are also important vectors of infectious agents:

  • Borrelia burgdorferi, Anaplasma phagocytophilum, and an Ehrlichia canis-like agent can infect cats (and humans), but their pathogenesis appears to be minimal in cats.24,25
  • Infections with Cytauxzoon felis or Francisella tularensis, both vectored by A americanum and D variabilis, are far more severe diseases; both can cause death in cats.26-28

Treatment Strategies

Tick control, similar to flea control, can be challenging, and also requires an integrated pest management strategy.18,19

CAPC recommends keeping cats indoors to protect them not only from ticks but from other parasitic infections. However, for cats that do venture outdoors, or those that share their living spaces with dogs, control ticks by:18,19

  1. Using a tick-control product (acaricide) approved for cats, such as:15,18
    • Topical (1-month efficacy): etofenprox, fipronil
    • Collar (8-month efficacy): flumethrin
  2. Implementing environmental management strategies:19
    • Limiting exposure to areas conducive to ticks
    • Excluding wildlife from areas near the house
    • Manicuring lawns and removing brush piles and leaf litter (“tick-scaping”)
    • Applying acaricides to yard and perimeter.

MITES

Cats can be infested with several mite species; the most common are Otodectes cynotis, Notoedres cati, Demodex cati, and D gatoi (Figure 3). Cheyletiella blakei, Lynxacarus radovskyi, and Sarcoptes scabiei rarely infest cats in the U.S.3,16,29-31

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FIGURE 3. Microscopic views of Otodectes cynotis, 200× magnification (A) and Demodex gatoi, approximately 400× magnification (B).
Courtesy National Center for Veterinary Parasitology, Oklahoma State University

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Life Cycle

The generic mite life cycle involves eggs, larvae, 2 nymphal stages, and adults, and takes 3 to 4 weeks to complete. All stages of mites can live in tunnels burrowed through the skin, within hair follicles, or on the surface of the host’s skin, but preferred sites of infestation depend on the species (Table 3).3,30,31 Mites are transmitted between hosts by direct contact with an infested animal.

Significance of Infestation

Infestation with mites generally results in local irritation and pruritus, but may progress to alopecia, exfoliative dermatitis, hyperkeratosis, or self-mutilation.17,29,31

All of the feline mite species discussed—other than Demodex species and L radovskyi—have been associated with transient infestations of humans.2,30

Treatment Strategies

Treatment of mite infestations is more straightforward than treatment of fleas or ticks.

  • Topical heartworm preventives for cats (selamectin or moxidectin/imidacloprid) are labeled to treat O cynotis; topical acaricides designed for use in the ear (ivermectin or milbemycin oxime) can also be used to treat O cynotis.3,30
  • For other mite species that can infest cats, macrocyclic lactones or fipronil are recommended; multiple doses are required to treat most infestations.3,30,31
  • Addition of antibiotics may be necessary if a secondary bacterial infection is present.

Since mites are transmitted through direct contact, treatment of all other cats in the household is necessary to prevent reinfestation; O cynotis also necessitates treatment of dogs and ferrets.30 Decontamination of bedding and grooming supplies is also recommended because some mites may survive off-host for short periods.3,30

LICE

Lice are a rather uncommon finding in cats that are receiving flea control; however, lice do infest cats on occasion, especially young, old, debilitated, or neglected cats.3,16 Felicola subrostratus is the chewing louse of cats (Figure 4).3

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FIGURE 4. Microscopic view of Felicola subrostratus, 100× magnification. Courtesy National Center for Veterinary Parasitology, Oklahoma State University

Life Cycle

Completion of the louse life cycle takes 1 to 2 months:3,16,32

  1. The female lays many eggs throughout her life and cements them to the hair of the host.
  2. A nymph hatches from the egg in 1 to 2 weeks; nymphs feed on tissue debris and undergo 2 additional molts to become adults.
  3. Adults also feed on tissue debris and mate while in the haircoat of the cat.

Significance of Infestation

Chewing lice attach at the base of the hair and are typically located around the head, neck, tail, and body openings.3,33 Infestation can cause irritation and pruritus, which can lead to rubbing, scratching, and alopecia of the infested areas.3,16,33

Treatment Strategies

Treatment of lice requires:

  • Use of an insecticide on the cat, including topical spot-on, shampoos, sprays, or powders; fipronil, imidacloprid, and selamectin are effective at killing lice.16,32,33
  • Treatment of all cats in the household because lice are transmitted through direct contact with infested animals.16
  • Decontamination of bedding and grooming supplies—fomites on which eggs may be located—by placing them in a clothes dryer for several hours.3

Lice are very species specific; there is no risk for transmission of lice to humans or pets other than cats.16

IN SUMMARY

There is no shortage of ectoparasites that cause disease in our feline patients, whether directly or indirectly. The diseases associated with these parasites can be quite severe in both cats and humans. Our clients want to protect their pets (and themselves) from these parasitic invaders, and the veterinary team is equipped with the knowledge and tools to:

  • Educate clients about these parasites
  • Treat the current infestation
  • Implement strategies to prevent future infestations.

Many safe and effective products are available for routine use in cats. Some products not only control the ectoparasites discussed in this article but also prevent or treat other parasitic infections.15 CAPC recommends broad-spectrum parasite control for every pet year-round; visit capcvet.org/resource-library for a comprehensive summary table of available ectoparasite control products for use in cats.

References

  1. Dyden MW, Rust MK. The cat flea: Biology, ecology, and control. Vet Parasitol 1994; 52(1-2):1-19.
  2. Moriello KA. Zoonotic skin diseases of dogs and cats. Anim Health Res Rev 2003; 4(2):157-168.
  3. Arther RG. Mites and lice: Biology and control. Vet Clin North Am Small Anim Pract 2009; 39(6):1159-1171.
  4. Blagburn BL, Dryden MW. Biology, treatment, and control of flea and tick infestations. Vet Clin North Am Small Anim Pract 009; 39(6):1173-1200.
  5. McElroy KM, Blagburn BL, Breitschwerdt EB, et al. Flea-associated zoonotic diseases of cats in the USA: Bartonellosis, flea-borne rickettsioses, and plague. Trends Parasitol 2010; 26(4):197-204.
  6. Eisen RJ, Gage KL. Transmission of flea-borne zoonotic agents. Annu Rev Entomol 2012; 57:61-82.
  7. Coles TB, Dryden MW. Insecticide/acaricide resistance in fleas and ticks infesting dogs and cats. Parasit Vectors 2014; 7:8.
  8. Harman DW, Halliwell RE, Greiner EC. Flea species from dogs and cats in north-central Florida. Vet Parasitol 1987; 23(1-2):135-140.
  9. Rust MK. Influence of photoperiod on egg production of cat fleas (Siphonaptera: Pulicidae) infesting cats. J Med Entomol 1992; 29:242-245.
  10. Silverman J, Rust MK. Extended longevity of pre-emerged adult cat flea (Siphonaptera: Pulicidae) and factors stimulating emergence from the pupal cocoon. Ann Entomol Soc Am 1985; 78:763-768.
  11. Olsen A. Annual Report. Lyngby, Denmark: Danish Infestation Laboratory, 1990, pp 59-60.
  12. Halos L, Beugnet F, Cardoso L, et al. Flea control failure? Myths and realities. Trends Parasitol 2014; 30(5):228-233.
  13. Siak M, Burrows M. Flea control in cats: New concepts and the current armoury. J Feline Med Surg 2013; 15(1):31-40.
  14. Dryden MW, Payne P, Zurek L. Fleas infesting our pets and homes. Kansas State University Agricultural Experiment Station and Cooperative Extension Service; September 2003.
  15. Inglis S (ed). Compendium of Veterinary Products. Shawnee, KS: Bayer Corporation, 2014.
  16. Dryden MW, Payne PA. Preventing parasites in cats. Vet Ther 2005; 6(3):260-267.
  17. Akucewich LH, Philman K, Clark A, et al. Prevalence of ectoparasites in a population of feral cats from north central Florida during the summer. Vet Parasitol 2002; 109(1-2):129-139.
  18. Dryden MW, Payne PA. Biology and control of ticks infesting dogs and cats in North America. Vet Ther 2004; 5(2):139-154.
  19. Stafford KC III. Tick Management Handbook. South Windsor, CT: The Connecticut Agricultural Experiment Station, 2007; available at ct.gov/caes/lib/caes/documents/publications/bulletins/b1010.pdf.
  20. Centers for Disease Control and Prevention. Ticks: Geographic distribution. Available at cdc.gov/ticks/geographic_distribution.html.
  21. Berrada ZL, Telford SR III. Burden of tick-borne infections on American companion animals. Top Companion Anim Med 2009; 24(4):175-181.
  22. Childs JE, Paddock CD. The ascendancy of Amblyomma americanum as a vector of pathogens affecting humans in the United States. Annu Rev Entomol 2003; 48:307-337.
  23. American Association of Veterinary Parasitologists. Otobius megnini. Available at aavp.org/wiki/arthropods/arachnids/metastigmata/argasidae/Otobius-megnini/.
  24. Breitschwerdt EB, Abrams-Ogg A, Lappin MR, et al. Molecular evidence supporting Ehrlichia canis-like infection in cats. J Vet Intern Med 2002; 16:642-649.
  25. Magnarelli LA, Bushmich SL, Ijdo JW, et al. Seroprevalence of antibodies against Borrelia burgdorferi and Anaplasma phagocytophilum in cats. Am J Vet Res 2005; 66:1895-1899.
  26. Blouin EF, Kocan AA, Glenn BL, et al. Transmission of Cytauxzoon felis (Kier, 1979) from bobcats, Felis rufus (Schreber), to domestic cats by Dermacentor variabilis (Say). J Wildl Dis 1984; 20(3):241-242.
  27. Petersen JM, Mead PS, Schriefer ME. Franscisella tularensis: An arthropod-borne pathogen. Vet Res 2009; 40(2):7.
  28. Reichard MV, Meinkoth JH, Edwards AC, et al. Transmission of Cytauxzoon felis to a domestic cat by Amblyomma americanum. Vet Parasitol 2009; 161(1-2):110-115.
  29. Craig TM, Teel PD, Dubuisson LM, Dubuisson RK. Lynxacarus radovskyi infestation in a cat. JAVMA 1993; 202(4):613-614.
  30. Curtis CF. Current trends in the treatment of Sarcoptes, Cheyletiella, and Otodectes mite infestation in dogs and cats. Vet Dermatol 2004; 15(2):108-114.
  31. Beale K. Feline demodicosis: A consideration in the itchy or overgrooming cat. J Feline Med Surg 2012; 14(3):209-213.
  32. Shanks DJ, Gautier P, McTier TL, et al. Efficacy of selamectin against biting lice on dogs and cats. Vet Rec 2003; 152(8):234-237.
  33. Pollmeier M, Pengo G, Longo M, Jeannin P. Effective treatment and control of biting lice, Felicola subrostratus (Nitzsch in Burmeister, 1838), on cats using fipronil formulations. Vet Parasitol 2004; 121(1-2):157-165.

Lindsay StarkyLindsay Starkey, DVM, is the Bayer Resident in Veterinary Parasitology at the National Center for Veterinary Parasitology, Oklahoma State University (ncvetp.org). Dr. Starkey received her DVM from Oklahoma State University.

 

 

Jay Stewart, DVM, owns and operates Aumsville Animal Clinic in Aumsville, Oregon, where he enjoys both clinical and management responsibilities in his multi-doctor small animal practice. Dr. Stewart received his DVM from Colorado State University.

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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' >Zimbabwe</option></select> <label for='input_6_10_6' id='input_6_10_6_label' >Country</label> </span> <div class='gf_clear gf_clear_complex'></div> </div></li> </ul></div> <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='Sign Up' onclick='if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_6"]){return false;} window["gf_submitting_6"]=true; jQuery("#gform_6").trigger("submit",[true]); }' /> <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' /> <input type='hidden' class='gform_hidden' name='gform_submit' value='6' /> <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' /> <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjNkNTNhNjhlOThlOGY4N2JlZWZiNTRmZDhlZDQ5OWI3Il0=' /> <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' /> <input type='hidden' class='gform_hidden' 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