Download - Methicillin-Resistant Staphylococcus Aureus (MRSA) in animals · 2018. 4. 3. · Methicillin-Resistant Staphylococcus Aureus (MRSA) in animals Mira J. Leslie, DVM, MPH Methicillin-resistant

Methicillin-Resistant Staphylococcus Aureus (MRSA) in animals

Mira J. Leslie, DVM, MPH

Methicillin-resistant Staphylococcus aureus (MRSA) is an emerging pathogen in pets and

people. In people it is now the leading cause of skin and soft tissue infections seen in

medical facilities, presenting mainly as boils and abcesses. More severe systemic

infections are also caused by MRSA. Infections caused by MRSA are difficult to treat

due to their resistance to beta lactam antimicrobials. MRSA infections are spread

primarily during direct contact among humans, and contact with contaminated fomites.

The close association of humans and animals, particularly household pets, food animals,

and horses has lead to a recognition that MRSA is also transmitted both as a zoonosis and

a reverse zoonoses. The epidemiology of human MRSA infection is evolving rapidly, as

is the information about the roles of various animals in the potential maintenance and

spread of MRSA.

In humans and animals, MRSA is generally categorized as being hospital associated or

community associated depending on the source of exposure. Different strains or clones

predominate in hospital vs. communities and in various animals and geographic areas.

Staph aureus is a gram positive bacteria found commonly on human skin and nasal

passages; CDC estimates that 25-30% of humans are colonized with Staph aureus and

1% with MRSA. Among veterinarians and techs tested for MRSA at an Internal

Medicine conference there was an overall prevalence of colonization of 6.5% and equine

veterinarians were higher at 15.6% (Weese S, EID 2006).

MRSA has been reported in pigs, horses, cattle, dogs, cats, and birds. MRSA infections

can be life threatening and difficult to treat; however, some animals may develop mild

disease or only become colonized. MRSA infections in humans and animals are often

associated with post operative and other wound infections, intravenous catheter site

infections, pneumonia, urinary tract infections and skin infections. The most reliable

clinical clue is non-response to empiric first line antimicrobial treatment. In a survey of

20 swine farms in Ontario Canada, MRSA was found on 45% of the farms, and was

cultured from 25% of the pigs and 20% of the farmers (Khanna T Vet Micro 2007).

MRSA is also an increasing problem in equine practice.

Humans are the main source of MRSA in households and direct transmission of MRSA

to pets and among families occurs. Pets may be implicated in recurrent MRSA infection

in households. Predominant MRSA strains found in pets and people in one area tend to be

the same.

Nosocomial transmission of MRSA to animals and to veterinary staff in small and large

animal veterinary settings has been reported. In veterinary settings and in households

with infected people or animals, practicing infection control is important. Strict hand

washing (using proper hand washing techniques) is mandatory every time a veterinary

patient is handled by any staff in veterinary clinics (including receptionists and

assistants). If hand washing is not possible, the use of alcohol based hand cleaners could

be substituted. MRSA infected animals should be isolated/separated from others and

gloves and gowns (barrier precautions) should be worn when dealing with wounds and

known or suspected MRSA infected patient. Veterinarians should be aware of proper

diagnosis and infection control in order to protect themselves, their staff, the animals and

their owners from this emerging pathogen.

JAVMA, Vol 233, No. 3, August 1, 2008 NASPHV Compendium of Veterinary Standard Precautions 415

Compendium of Veterinary Standard

Precautions for Zoonotic Disease Prevention in Veterinary Personnel

National Association of State Public Health Veterinarians

Veterinary Infection Control Committee 2008

Preface................................................................................................................................................................ 417I...INTRODUCTION..................................................................................................................................... 417

A..BACKGROUND.AND.OBJECTIVES.................................................................................................... 417B..CONSIDERATIONS............................................................................................................................. .418

II..ZOONOTIC.DISEASE.TRANSMISSION.................................................................................................. 418A..SOURCE............................................................................................................................................... 418B..HOST.SUSCEPTIBILITY...................................................................................................................... .418C..ROUTES.OF.TRANSMISSION............................................................................................................. 418.

1..CONTACT.TRANSMISSION............................................................................................................ 4182..AEROSOL.TRANSMISSION............................................................................................................. 4183..VECTOR-BORNE.TRANSMISSION................................................................................................. 418

III. VETERINARY.STANDARD.PRECAUTIONS............................................................................................ 419A..PERSONAL.PROTECTIVE.ACTIONS.AND.EQUIPMENT................................................................. 419

1..HAND.HYGIENE............................................................................................................................. 4192..USE.OF.GLOVES.AND.SLEEVES.................................................................................................... 4193..FACIAL.PROTECTION.................................................................................................................... 4194..RESPIRATORY.TRACT.PROTECTION........................................................................................... 4195..PROTECTIVE.OUTERWEAR.......................................................................................................... 420

a..Laboratory coats, smocks, and coveralls........................................................................................ 420b..Nonsterile gowns........................................................................................................................... 420c..Footwear....................................................................................................................................... 420d..Head covers.................................................................................................................................. 420

6..BITE.AND.OTHER.ANIMAL-RELATED.INJURY.PREVENTION................................................... 420B..PROTECTIVE.ACTIONS.DURING.VETERINARY.PROCEDURES..................................................... 420

1..PATIENT.INTAKE............................................................................................................................ 4202..EXAMINATION.OF.ANIMALS........................................................................................................ 4203..INJECTIONS,.VENIPUNCTURE,.AND.ASPIRATION.PROCEDURES........................................... 421

a..Needlestick injury prevention......................................................................................................... 421b..Barrier protection.......................................................................................................................... 421

4..DENTAL.PROCEDURES.................................................................................................................. 421.5..RESUSCITATION............................................................................................................................. 4216..OBSTETRICS.................................................................................................................................... 4217..NECROPSY...................................................................................................................................... 4218..DIAGNOSTIC-SPECIMEN.HANDLING.......................................................................................... 422............

C..ENVIRONMENTAL.INFECTION.CONTROL..................................................................................... 4221..ISOLATION.OF.ANIMALS.WITH.INFECTIOUS.DISEASES.......................................................... 4222..CLEANING.AND.DISINFECTION.OF.EQUIPMENT.AND.ENVIRONMENTAL.SURFACES....... 4223..HANDLING.OF.LAUNDRY............................................................................................................. 4224..DECONTAMINATION.AND.SPILL.RESPONSE.............................................................................. 4225..VETERINARY.MEDICAL.WASTE................................................................................................... 4236..RODENT.AND.VECTOR.CONTROL.............................................................................................. 4237..OTHER.ENVIRONMENTAL.CONTROLS....................................................................................... 423

IV..EMPLOYEE.HEALTH............................................................................................................................... 423A..GENERAL............................................................................................................................................ 423

1..EMPLOYEE.VACCINATION.POLICIES.AND.RECORD.KEEPING............................................... 423a..Rabies........................................................................................................................................... 423b..Tetanus......................................................................................................................................... 423c..Influenza....................................................................................................................................... 423

416 NASPHV Compendium of Veterinary Standard Precautions JAVMA, Vol 233, No. 3, August 1, 2008

2..MANAGEMENT.AND.DOCUMENTATION.OF.EXPOSURE.INCIDENTS.................................... 423.3..STAFF.TRAINING.AND.EDUCATION........................................................................................... .424.

B..IMMUNOCOMPROMISED.PERSONNEL............................................................................................ 424.V..CREATING.A.WRITTEN.INFECTION.CONTROL.PLAN....................................................................... 424

A..INFECTION.CONTROL.PERSONNEL............................................................................................... 424B..COMMUNICATING.AND.UPDATING.THE.INFECTION.CONTROL.PLAN.................................. ..425

1..AVAILABILITY.................................................................................................................................. 4252..LEADERSHIP................................................................................................................................... 4253..NEW.STAFF..................................................................................................................................... 4254..CONTINUING.EDUCATION.......................................................................................................... 4255..REVIEW.AND.REVISION................................................................................................................ 4256..COMPLIANCE................................................................................................................................. 425

VI..REFERENCES........................................................................................................................................... 425Appendices

..1—Zoonotic.diseases.of.importance.in.the.United.States,.2008................................................................. 428

..2—Selected.disinfectants.used.in.veterinary.practice................................................................................. 430

..3—Model.infection.control.plan.for.veterinary.practices,.2008................................................................. 431

.. ....................................................... .........The.NASPHV.VICC.Brigid.L..Elchos,.rn,.dvm,.(Co-Chair),.State.Public.Health.Veterinarian,.Mississippi.Board.of.Animal.Health,.Jackson,.MS.39207.

Joni.M..Scheftel,.dvm,.mph,.dacvpm,.(Co-Chair),.State.Public.Health.Veterinarian,.Minnesota.Department.of.Health,.Saint.Paul,.MN..........55155.

Bryan.Cherry,.vmd,.phd,.Deputy.State.Public.Health.Veterinarian,.New.York.State.Department.of.Health,.Albany,.NY.12237.

Emilio.E..DeBess,.dvm,.mpvm,.State.Public.Health.Veterinarian,.Oregon.Department.of.Human.Services,.Portland,.OR.97232.

Sharon.G..Hopkins,.dvm,.mph,.Public.Health.Veterinarian,.Public.Health—Seattle.&.King.County,.Seattle,.WA.98104.

Jay.F..Levine,.dvm,.mph,.dacvpm,.Department.of.Epidemiology.and.Public.Health,.College.of.Veterinary.Medicine,.North.Carolina.State... University,.Raleigh,.NC.27606.

Carl.J..Williams,.dvm,.ma,.State.Public.Health.Veterinarian,.North.Carolina.Department.of.Health.and.Human.Services,.Raleigh,.NC.. 27699.

Consultants.to.the.Committee

Michael.R..Bell,.md,.Centers.for.Disease.Control.and.Prevention.(CDC),.Atlanta,.GA.33033.

Glenda.D..Dvorak,.dvm,.mph,.Center.for.Food.Security.and.Public.Health,.Ames,.IA.50011.

Christine.A..Flora,.mlt.(ascp),.American.Animal.Hospital.Association.(AAHA),.Lakewood,.CO.80228.

Jo.Hofmann,.md,.Council.of.State.and.Territorial.Epidemiologists.(CSTE),.Atlanta,.GA.30341.

Boris.I..Pavlin,.md,.Johns.Hopkins.Bloomberg.School.of.Public.Health,.Baltimore,.MD.21205.

Oreta.M..Samples,.cvt,.mph,.National.Association.of.Veterinary.Technicians.in.America.(NAVTA),.Alexandria,.VA.22304.

Jamie.L..Snow,.dvm,.mph,.United.States.Department.of.Agriculture,.Animal.and.Plant.Health.Inspection.Service,.Veterinary.Services.....(USDA.APHIS.VS),.Fort.Collins,.CO.80526.

Rebecca.E..Stinson-Dixon,.dvm,.American.Veterinary.Medical.Association.(AVMA),.Schaumburg,.IL.60173.

This.article.has.not.undergone.peer.review;.opinions.expressed.are.not.necessarily.those.of.the.American.Veterinary.Medical.. ....Association.

Address.correspondence.to.Dr..Scheftel,.NASPHV.VICC,.Acute.Disease.Investigation.and.Control.Section,.Minnesota.Department.of.....Health,.625.N.Robert.St,.Saint.Paul,.MN.55155-2538..


Preface

Veterinary. practices. are. unique. environments. that.bring.humans. into.close. contact.with.many. species.of.animals..Whether.in.a.clinic.or.in.field.settings,.veteri-nary.personnel.are.routinely.exposed.to.infectious.patho-gens,.many.of.which.are.zoonotic.(transmitted.from.ani-mals.to.humans)..Some.reported.zoonoses.in.veterinary.personnel. include. multidrug-resistant. salmonellosis,.cryptosporidiosis,.cat-associated.plague,.sporotrichosis,.methicillin-resistant. Staphylococcus aureus infection,.psittacosis,.and.dermatophytosis..Infection.control.mea-sures.vary.from.practice.to.practice.and.are.often.insuf-ficient.to.prevent.zoonotic.disease.transmission..

The. Veterinary. Standard. Precautions. outlined. in.this.Compendium.are.designed.to.minimize.transmis-sion. of. zoonotic. pathogens. from. animals. to. veteri-nary.personnel. in.private.practice..The.Compendium.is. based. on. current. scientific. evidence. and. the. VICC.members’. collective.experience.and.knowledge.of. the.veterinary.profession..

I. INTRODUCTION...A. BACKGROUND AND OBJECTIVES:

Zoonotic.diseases.are.occupational.hazards.faced.by.veterinary.personnel.on.a.daily.basis.1.Although.the.scope.of.zoonotic.disease. risk.has.been.docu-mented,. guidance. for. infection. control. in. general.veterinary.practice.has.been.limited..Currently,.in-fection.control.measures.vary.tremendously.among.veterinary. facilities. and. are. often. insufficient. to.prevent.zoonotic.disease.transmission.2,3.In.human.medicine,. infection. control. evolved. substantially.with. the. recognition. of. transmission. of. HIV. and.hepatitis. B. and. C. viruses. to. health-care. workers;.currently,. the. cornerstone. of. infection. control. in.human.health-care.settings.is.the.consistent.use.of.Standard.Precautions.4.Similarly,. the.2003.US.out-break.of.monkeypox.virus.infection.among.humans.in.6.states,.in.which.18.of.71.(25%).affected.indi-viduals.were.veterinary.personnel,.highlighted.the.need.for.infection.control.precautions.in.veterinary.medicine.5,6.

Veterinary. Standard. Precautions. are. infection.control.guidelines. intended.to.minimize. the.risk.of. occupational. zoonotic. infections. from. recog-nized.and.as.yet.unrecognized.sources..Regardless.of.the.diagnosis.made.for.a.particular.animal,.these.precautions. should. be. used. whenever. personnel.may.be.exposed. to.potentially. infectious.materi-als,.including.feces,.blood,.body.fluids,.exudates,.and.nonintact.skin..

New.infectious.diseases.are.continually.emerg-ing.7. Approximately. 868. of. 1,415. (61%). known.human.pathogens.are.zoonotic,.and.approximate-ly.132.of.175.(75%).emerging.diseases.that.affect.humans. are. zoonotic.8. Global. commerce,. trade,.and. travel. continue. to. increase. the. potential. for.exposure.to.zoonotic.pathogens..

Although. reports. of. exotic. infections. in. vet-erinary.personnel.dramatically.illustrates.the.need.for. routine. infection. control. precautions,. use. of.VSP.would.minimize.exposure.to.many.zoonotic.pathogens.encountered.more.frequently..Reported.

occupationally. acquired. zoonotic. infections. in-clude.the.following:.•. Multidrug-resistant. salmonellosis. outbreaks.

with.zoonotic.transmission.to.veterinary.staff.and.students.9–11

•. Cryptosporidiosis.among.veterinary.students.12–16.

•. Cat-associated. plague. (Yersinia pestis. infec-tion).in.veterinary.personnel.17.

•. Cat-associated. sporotrichosis. in. veterinary.personnel.18–22.

•. Transmission.of.methicillin-resistant.S aureus.infections. among. veterinary. personnel. and.equine,. bovine,. porcine,. canine,. and. feline..patients.11,23–33

•. Psittacosis.34–37

•. Dermatophytosis.(ringworm).38

Veterinary.Standard.Precautions.include.strat-egies. to. reduce. the. potential. for. bites. and. other.trauma. that. may. result. in. exposure. to. zoonotic.pathogens.. During. their. careers,. approximately.two. thirds. of. veterinary. medical. personnel. are.hospitalized. or. unable. to. work. for. considerable.periods. of. time. as. a. result. of. animal-related. in-jury.1,39–42.Dog.and.cat.bites,.kicks,.scratches.from.cats,.and.crush.injuries.account.for.most.occupa-tional. injuries. among. veterinary. personnel.1,39–42.According.to.1.report,43.approximately.3%.to.18%.of.dog.bites.and.28%.to.80%.of.cat.bites.become.infected..Most.infected.dog-.and.cat-bite.wounds.contain.mixed.aerobic.and.anaerobic.bacteria..The.most. commonly. isolated. aerobes. are. Pasteurella multocida.(cats),.Pasteurella canis.(dogs),.strepto-cocci,.staphylococci,.Moraxella.spp,.and.Neisseria weaveri;. the. most. commonly. isolated. anaerobes.are. various. species. of. Fusobacterium,. Bacteroi-des,.Porphyromonas,.and.Prevotella.43. In.addition,.rare.but.serious.systemic.infections.with.invasive.pathogens. such. as. Capnocytophaga canimorsus,.Bergeyella zoohelcum,. Bartonella henselae,. and.CDC.Group.NO-1.may.develop.following.bites.or.scratches.43–47

Needlestick. injuries. are. also. among. the.most.frequent.accidents.in.the.veterinary.workplace.48,49.The.most.common.needlestick. injury. is. inadver-tent.injection.of.a.vaccine.1,50,51.In.a.1995.survey.of.701. veterinarians,. accidental. self-injection. of. ra-bies.virus.vaccine.was.reported.by.27%.of.respon-dents;. among. large-animal. practice. respondents,.23%. had. accidentally. self-injected. vaccines. con-taining.live.Brucella.organisms.1.Additionally,.nee-

AbbreviAtions

ACIP Advisory Committee on Immunization PracticesNASPHV National Association of State Public Health VeterinariansNIOSH National Institute of Occupational Safety and HealthOSHA Occupational Safety and Health AdministrationVICC Veterinary Infection Control CommitteeVSP Veterinary Standard Precautions


dle. punctures. sustained. during. procedures. such.as. fine-needle. aspiration. are. potential. sources. of.zoonotic.pathogens.52.

Based.on.the.need.for.infection.control.guide-lines. that. were. specific. to. veterinary. medicine,.the.VICC.set.the.following.objectives.for.the.cre-ation.of. the.Compendium:. to. raise. awareness.of.the. scope. of. zoonotic. disease. risk. in. veterinary.medicine;.address.issues.specific.to.the.veterinary.profession;. establish.practical,. science-based.vet-erinary.infection.control.guidance;.and.provide.a.model.infection.control.plan.for.use.in.individual.veterinary.facilities..

...B. CONSIDERATIONS:Although. elimination. of. all. risks. associated.

with.zoonotic.pathogens.is.not.possible,. the.pur-pose.of.this.Compendium.is.to.provide.reasonable.guidance.for.minimizing.disease.and.injury.among.veterinary.personnel.in.clinical.settings..The.guide-lines.are.intended.to.be.adapted.to.individual.needs.and. circumstances,. but. veterinary.practices.must.first.comply.with. federal,. state,.and. local.author-ity. regulations,. and. modifications. should. adhere.to.the.basic.principles.of.infection.control.that.are.necessary. to.prevent. spread.of. occupational. zoo-notic.pathogens.by.all.routes.of.transmission..The.authors.of.this.Compendium.advocate.a.multifac-eted.approach. to. infection.control,. incorporating.personal.protective.activities.with.appropriate.ad-ministrative. and. environmental. engineering. con-trol.measures..

Employers. should. promote. safe. work. habits..The.cost.of.implementing.these.guidelines.should.be. compared. with. the. potential. consequences. of.inadequate.infection.control,. including.sick.leave.or.hospitalization.of.personnel,.loss.of.credibility,.and. litigation.53–55.Training. is. an. essential. part. of.VSP.implementation.that.is.most.effective.if.each.employee.understands.the.relevance.of.these.guide-lines.to.his.or.her.health.and.the.health.of.others..

Client.education. that.addresses. issues. such.as.the. importance. of. rabies. vaccination. of. animals,.comprehensive.internal.and.external.parasite.con-trol,.and.bite.prevention.will.also.help.protect.vet-erinary.staff.from.zoonotic.diseases..Veterinarians.are.accessible.and.expert.sources.of.information.re-garding.zoonotic.diseases.and.should.be.prepared.to.inform.clients.of.risks.specific.to.their.commu-nity.. Written. educational. information. should. be.made.available.in.hospital.and.clinic.waiting.areas.and.on.practice.Web.sites.

II. ZOONOTIC DISEASE TRANSMISSION.Transmission.of.pathogens. requires.3. elements:.

a.source.of. the.organism,.a.susceptible.host,.and.a.means. of. transmission. between. them.4. Infection.control.involves.eliminating.or.isolating.the.source,.reducing. host. susceptibility,. or. interrupting. trans-mission.of.the.agent..A. SOURCE:.

Animal. sources. of. infection. include. animals.that.harbor.endogenous.microflora.that.are.patho-genic. to.humans,. apparently.healthy. animals. that.

are.carriers.of.an.infectious.agent,.and.animals.that.are.clinically.ill..Environmental.sources.of.infection.include.contaminated.walls,.floors,.counters,.cages,.bedding,.equipment,.supplies,.feed,.soil,.and.water..

.....B. HOST SUSCEPTIBILITY:Human. susceptibility. to. infection. varies.

greatly..Factors.influencing.susceptibility.include.vaccination.status,.age,.underlying.diseases,. im-munosuppression,. pregnancy,. and. deficiencies.in. the. body’s. primary. defense. mechanisms. (eg,.damage.to.intact.skin,.loss.of.cough.reflex,.or.re-duced.production.of.stomach.acid)..Humans.may.be.immune.to.or.able.to.resist.colonization.by.an.infectious.agent,.become.asymptomatic.carriers,.or.develop.illness..

C. ROUTES OF TRANSMISSION:.Pathogens.are.transmitted.via.3.main.routes:.

contact,. aerosol,. and.vector-borne. transmission..Some.agents.may.be.transmitted.by.more.than.1.route.4

..1..CONTACT.TRANSMISSION.Contact. transmission. occurs. when. patho-

gens.from.animals.or.their.environments.enter.the.human.host.through.3.mechanisms:.inges-tion,. cutaneous. or. percutaneous. exposure,. or.mucous.membrane.exposure..Direct.transmis-sion. may. occur. during. examination,. bathing,.and. general. handling. of. animals. or. during.administration. of. treatments.. Indirect. trans-mission. involves.contact.with.a.contaminated.intermediate. object,. such. as. during. cleaning.of.cages.and.equipment.or.during.handling.of.soiled.laundry.4.

..2..AEROSOL.TRANSMISSION.Aerosol. transmission. occurs. when. patho-

gens. travel. through. the. air. to. enter. the. host..Aerosols. may. be. large. droplets. that. are. de-posited.on.the.mucous.membranes.or.smaller.particles.that.are.inhaled..For.most.pathogens.transmitted.by.this.route,.specific.data.defining.risk.of.infection.are.limited;.in.general,.risk.of.aerosol. transmission. increases. with. proximity.to.the.source.and.duration.of.exposure..

Large. droplets. are. created. by. coughing,.sneezing,. and. vocalization. and. by. procedures.such.as.lancing.abscesses.and.dentistry..Particles.that.can.be. inhaled.may.be.generated.through.procedures. such. as. suction,. bronchoscopy,.sweeping,.vacuuming,.and.high-pressure.spray-ing..Certain.aerosolized.pathogens.may.remain.infective.over.long.distances,.depending.on.par-ticle. size,. the.nature.of. the.pathogen,. and.en-vironmental.factors.4,56.Two.zoonotic.pathogens.known.to.be.transmitted.over.long.distances.are.Coxiella burnetii57–59.and.Mycobacterium bovis.60.

..3..VECTOR-BORNE.TRANSMISSION.Vector-borne.transmission.occurs.when.vec-

tors.such.as.mosquitoes,.fleas,.and.ticks.trans-mit.pathogens..Animals.may.bring.flea.and.tick.vectors.into.contact.with.veterinary.personnel..Working.in.outdoor.settings.may.increase.risk.of.exposure.to.arthropods.and.other.biological.vectors..


III. VETERINARY STANDARD PRECAUTIONS A. PERSONAL PROTECTIVE ACTIONS AND EQUIPMENT:.

...1..HAND.HYGIENE.Consistent,. thorough.hand.hygiene. is. the.

single.most.important.measure.veterinary.per-sonnel.can. take. to. reduce. the.risk.of.disease.transmission.4,61,62.In.veterinary.practice,.hand.washing.is.preferred.over.the.use.of.hand.rubs.because. hands. are. routinely. contaminated.with.organic.material..

Hand.washing.with.plain.(nonantimicro-bial). soap. and. running. water. mechanically.removes. organic. material. and. reduces. the.number. of. transient. organisms. on. the. skin,.whereas. antimicrobial. soap. kills. or. inhibits.growth. of. transient. and. resident. flora.63,64.Plain.or.antibacterial.products.are.appropri-ate.for.routine.use..To.reduce.the.opportunity.for.cross-contamination,.liquid.or.foam.soap.products. should.be. selected. rather. than.bar.soaps.. Refillable. dispensers. should. be. com-pletely. emptied,. cleaned,. and. then. refilled.to. prevent. creation. of. a. bacterial. reservoir..Moisturizing. soaps. can. preserve. skin. integ-rity.and.encourage.compliance.with.hand.hy-giene. protocols. among. veterinary. staff.. Dry,.cracked. skin. is. painful,. and. indicates. skin.barrier.disruption..

Hands.should.be.washed.between.animal.contacts.and.after.contact.with.feces,.blood,.body. fluids,. and. exudates.. Staff. members.who. have. animal. contact. should. not. wear.artificial. nails. and. should. keep. fingernails.short.61,65.Wearing.rings.may.reduce. the.ef-fectiveness. of. hand. hygiene.61. Hand. wash-ing.should.focus.on.thorough.cleaning.of.all.hand.surfaces.

The.correct.technique.for.hand.washing.is.as.follows66:•. Wet.hands.with.running.water.•. Place.soap.in.palms.•. Rub.hands.together.to.make.a.lather.•. Scrub.hands.vigorously.for.20.seconds.•. Rinse.soap.off.hands.•. Dry.hands.with.a.disposable.towel.•. Turn.off.faucet.using.the.disposable.towel.

as.a.barrier.

Alcohol-based. hand. rubs. are. highly. effec-tive.against.bacteria.and.enveloped.viruses.and.may.be.used.if.hands.are.not.visibly.soiled.61,67,68.However,. hand. rubs. are. less. effective. against.some.nonenveloped.viruses.(eg,.norovirus,.ro-tavirus,. and. parvovirus),. bacterial. spores. (eg,.Bacillus anthracis. and.Clostridium difficile),.or.protozoal.parasites.(eg,.cryptosporidia).61,68,69.

The.correct.technique.for.use.of.hand.rubs.is.as.follows.61:•. Apply.alcohol-based.hand.rub.to.palm.of.

1.hand.•. Cover.all.surfaces.of.hands.and.fingers.•. Continue.to.rub.hands.together.until.dry.

When. running. water. is. not. available,. the.mechanical. action. of. a. moist. wipe. may. en-hance. the. effectiveness. of. an. alcohol-based.hand. rub,. especially. when. hands. are. visibly.soiled..In.sole.use,.moist.wipes.are.not.as.ef-fective.as.alcohol-based.hand.rubs.or.washing.hands.with.soap.and.running.water.61.

...2..USE.OF.GLOVES.AND.SLEEVESGloves. reduce. the. risk.of.pathogen. trans-

mission.by.providing.barrier.protection..Nev-ertheless,.wearing.gloves.(including.sleeves).is.not. a. substitute. for. hand. washing.70,71. Wear-ing.gloves.is.not.necessary.when.examining.or.handling. healthy. animals.. Gloves. should. be.worn.when.an.animal.has.evidence.of.disease.or. its. medical. history. is. unknown. and. worn.routinely.when.contact.with.feces,.blood,.body.fluids,. secretions,. excretions,. exudates,. and.nonintact.skin.is.likely..Gloves.should.also.be.worn. when. cleaning. cages,. litter. boxes,. and.environmental.surfaces..

Gloves.should.be.changed.between.exami-nations.of.individual.animals.or.animal.groups.(eg,. litters. of. puppies. or. kittens,. groups. of.cattle),. between. dirty. and. clean. procedures.performed.on.a. single.patient,. and.whenever.torn..Gloves.should.be.removed.promptly.after.use,. and. contact. between. skin. and. the.outer.glove. surface. should. be. avoided.. Disposable.gloves. should. not. be. washed. and. reused.72,73.Immediately.after.glove.removal,.hands.should.be.washed.because.gloves.can.have.undetected.perforations. or. hands. may. be. contaminated.unknowingly.during.glove.removal..

.Gloves.are.available.in.a.variety.of.materi-als..Choice.of.gloves.depends.on.their.intended.use..If.allergic.reactions.to.latex.are.a.concern,.acceptable.alternatives.include.nitrile.or.vinyl.gloves..Further.information.regarding.preven-tion.of.allergic. reactions. to.natural. rubber. in.the.workplace.is.provided.by.NIOSH.74.

...3..FACIAL.PROTECTION.Facial. protection. prevents. exposure. of.

mucous. membranes. of. the. eyes,. nose,. and.mouth. to. infectious. materials.. Facial. protec-tion. should. be. used. whenever. exposures. to.splashes.or.sprays.are.likely.to.occur,4,53,75.such.as.those.generated.during.lancing.of.abscesses,.flushing.wounds,.dentistry,.nebulization,.suc-tioning,.lavage,.and.necropsy.

Facial.protection. includes.a.surgical.mask.worn. with. goggles. or. a. face. shield.. Surgical.masks. provide. adequate. protection. during.most.veterinary.procedures. that.generate.po-tentially.infectious.large.droplets..

...4..RESPIRATORY.TRACT.PROTECTION.Respiratory.tract.protection.is.designed.to.

protect. the.airways.of. the.wearer. from. infec-tious. agents. that. are. transmitted. via. inhala-tion.of.small.particles..Although.the.need.for.this.type.of.protection.is.limited.in.veterinary.medicine,.it.may.be.appropriate.in.certain.situ-ations,. such.as.during. investigations.of.abor-


tion.storms.in.small.ruminants.(Q.fever),.ab-normally. high. mortality. rates. among. poultry.(avian. influenza),. respiratory. disease. in. an..M bovis–positive. herd. (bovine. tuberculosis),.and.ill.psittacines.(avian.chlamydiosis)..

Disposable.particulate.respirators.often.re-semble. surgical. or. dust. masks. but. fit. closely.to. the.wearer’s. face.and.are.designed. to.filter.smaller. particles. (surgical. masks. are. not. de-signed.to.prevent.inhalation.of.small.particles)..A.variety.of.inexpensive.respirators,.such.as.the.commonly.used.NIOSH-certified.N95.respira-tor.(designed.to.filter.at.least.95%.of.airborne.particles).are. readily.available.76.Fit-testing. is.necessary. to.ensure.an.effective. seal.between.a. respirator. and. the. wearer’s. face.. Additional.information.about.respirators,.fit-testing,.and.the.OSHA.Respiratory.Protection.Standard. is.provided.by.NIOSH.and.OSHA.76,77.

...5..PROTECTIVE.OUTERWEAR.

.......a..Laboratory coats, smocks, and coveralls.Laboratory. coats,. smocks,. and. cover-

alls. are. designed. to. protect. street. clothes.or. scrubs. from. contamination.. They. are.generally.not.fluid.resistant,.so.they.should.not. be. used. in. situations. where. splash-ing. or. soaking. with. potentially. infectious.liquids. is. anticipated.. Garments. should. be.changed. promptly. whenever. they. become.visibly.soiled.or.contaminated.with.feces.or.body.fluids..For.most.personnel,.outerwear.should. be. changed. and. laundered. daily..These.garments.should.not.be.worn.outside.of.the.work.environment.4,78,79.

.......b..Nonsterile gowns.Gowns.provide.better.barrier.protection.

than. laboratory. coats.. Permeable. gowns.can.be.used. for.general. care.of. animals. in.isolation.. Impermeable. gowns. should. be.used. when. splashes. or. large. quantities. of.body.fluids.are.present.or.anticipated..Dis-posable.gowns.should.not.be.reused..Reus-able. fabric. gowns. may. be. used. repeatedly.to.care.for.the.same.animal.in.isolation,.but.should.be.laundered.between.contacts.with.different. patients. or. whenever. soiled.. Use.of. gloves. is. indicated.whenever.gowns.are.worn,. and. the. outer. (contaminated). sur-face.of.a.gown.should.only.be.touched.with.gloved.hands..Gowns.and.gloves.should.be.removed. and. placed. in. the. laundry. or. re-fuse.bin.before.leaving.the.animal’s.environ-ment..Hands.should.be.washed.immediately.afterwards.53.

To. avoid. cross-contamination,. gowns.should.be.removed.as.follows:.•. After. unfastening. ties,. peel. the. gown.

from.the.shoulders.and.arms.by.pulling.on.the.chest.surface.with.gloved.hands.

•. Remove. the. gown,. avoiding. contact.between. its. outer. surface. and. clean.surfaces.

•. Wrap.the.gown.into.a.ball.for.disposal.

while.keeping.the.contaminated.surface.on.the.inside.

•. Remove.gloves.and.wash.hands.•. If.body.fluids.have.soaked.through.the.

gown,. promptly. remove. the. contami-nated.clothing.and.wash.the.skin.

. c..FootwearFootwear.should.be.suitable.for.the.spe-

cific. working. conditions. (eg,. rubber. boots.for.farm.work).and.should.protect.person-nel. from. exposure. to. infectious. material.as. well. as. from. trauma.. Recommendations.include.shoes.or.boots.with.thick.soles.and.closed-toe. construction. that. are. imperme-able. to. liquid. and. easy. to. clean.. Footwear.should.be.cleaned.to.prevent.transfer.of.in-fectious.material. from.one. environment. to.another,. such. as. between. farm. visits. and.before.returning. from.a.field.visit. to.a.vet-erinary. facility. or. home.. Disposable. shoe.covers.or.booties.add.an.extra.level.of.pro-tection.when.heavy.quantities.of.infectious.materials.are.present.or.expected..

...d..Head coversDisposable.head.covers.provide.a.barrier.

when. gross. contamination. of. the. hair. and.scalp. is. expected.. Disposable. head. covers.should.not.be.reused.

..........6...BITE.AND.OTHER.ANIMAL-RELATED..

. INJURY.PREVENTIONVeterinary.personnel.should.take.all.nec-

essary.precautions.to.prevent.animal-related.injuries.. Preventive. measures. include. use.of. physical. restraints,. bite-resistant. gloves,.muzzles,. sedation. or. anesthesia,. and. reli-ance. on. experienced. veterinary. personnel.rather.than.owners.to.restrain.animals.80.Re-quest.that.owners.notify.veterinary.person-nel.before.contact. is. initiated. if. the.animal.is.aggressive..Aggressive.tendencies.and.bite.history. should. be. recorded. and. communi-cated.to.personnel..Practitioners.should.re-main.alert.for.changes.in.their.patients’.be-havior.. Veterinary. personnel. working. with.large.animals.should.have.an.escape.route.in.mind.at.all.times.1,42.

. B. PROTECTIVE ACTIONS DURING VETERI- NARY PROCEDURES:.........1..PATIENT.INTAKE

Waiting.rooms.should.be.a.safe.environment.for.clients,.animals,.and.employees..

Aggressive.animals.and.those.that.have.a.po-tentially.communicable.disease.should.be.placed.directly.into.an.examination.room..Animals.with.respiratory.or.gastrointestinal.signs.or.that.have.a.history.of.exposure.to.a.known.infectious.agent.should. be. brought. through. an. entrance. other.than.the.main.entrance.81.If.possible,.an.exami-nation. room. should. be. designated. for. animals.with.potentially.infectious.diseases.

.2..EXAMINATION.OF.ANIMALSAll. veterinary. personnel. should. wash. their.

hands.between.examinations.of.individual.ani-


mals.or.animal.groups.(eg,.litters.of.puppies.or.kittens,.groups.of.cattle)..Routine.hand.hygiene.is. the. most. effective. way. to. prevent. transmis-sion. of. zoonotic. diseases.. Every. examination.room.should.have.a.source.of.running.water,.a.soap.dispenser,.and.paper.towels..Alcohol-based.hand.rubs.may.be.provided.for.use.in.conjunc-tion.with.hand.washing..

Veterinary.personnel.should.wear.protective.outerwear. and. use. gloves. and. other. protec-tive. equipment. appropriate. for. the. situation..Animals. with. potentially. infectious. diseases.should. be. examined. in. a. dedicated. examina-tion. room.and. should. remain. there.until. ini-tial.diagnostic.procedures.and.treatments.have.been.performed.

. .....3. INJECTIONS,.VENIPUNCTURE,.AND..

............ASPIRATION.PROCEDURES......a..Needlestick injury prevention.

Needlestick.injuries.are.of.concern.in.vet-erinary.medical.settings.because.they.can.re-sult.in.the.inoculation.of.live.vaccines.or.in-fective.aspirate.materials..Additionally,. skin.breaks.from.needlesticks.can.act.as.a.portal.of. entry. for. environmental. pathogens.. The.risk. of. exposure. to. blood-borne. pathogens.from. needlestick. injuries. is. inherently. dif-ferent.in.veterinary.medicine.than.in.human.medicine..Contact.with.animal.blood.(except.primate. blood). has. not. been. reported. as. a.source.of.occupationally.acquired.infection;.nevertheless,.percutaneous.and.mucosal.ex-posure.to.blood.and.blood.products.should.be.avoided..

After.injection.of.vaccines.containing.live.organisms.or.aspiration.of.body.fluids.or.tis-sue,.the.used.syringe.with.the.attached.nee-dle. should. be. placed. in. a. sharps. container.(a. container. designed. for. safe. collection. of.medical. articles. that. may. cause. punctures.or. cuts. to. those. handling. them).. Although.not. ideal,. following. most. other. veterinary.procedures,. the. needle. and. syringe. may. be.separated. for. disposal. of. the. needle. in. the.sharps. container.. This. can. be. most. safely.accomplished.by.use.of. the.needle. removal.device.on.the.sharps.container,.which.allows.the.needle.to.drop.directly.into.the.contain-er..Alternatively,.the.needle.may.be.removed.from.the.syringe.by.use.of.forceps..Uncapped.needles. should. never. be. removed. from. the.syringe. by. hand.. In. addition,. needle. caps.should.not.be.removed.by.mouth.

Puncture-.and.leak-proof.sharps.contain-ers.should.be.located.in.every.area.in.which.animal.care.occurs.82–84.After.disposal,.sharps.should.not.be.transferred.from.one.container.to.another..Devices.that.cut.needles.prior.to.disposal.should.not.be.used.because.they.in-crease.the.potential.for.aerosolization.of.the.contents.82.

When.it. is.absolutely.necessary.to.recap.needles. as. part. of. a. medical. procedure. or.

protocol,.a.forceps.can.be.used.to.replace.the.cap.on.the.needle.or.a.1-handed.scoop.tech-nique.may.be.employed.as.follows85:•.. Place.the.cap.on.a.horizontal.surface.•. Hold.the.syringe.with.attached.needle.in.

1.hand.•. Use.the.needle.to.scoop.up.the.cap.with-

out.use.of.the.other.hand.•. Tighten. the.cap.by.pushing. it.against.a.

hard.surface.b..Barrier protection

Gloves.should.be.worn.during.venipunc-ture.of.animals.suspected.of.having.an.infec-tious.disease. and.when.performing. soft. tis-sue. aspiration. procedures.. Currently,. there.are. no. data. indicating. that. venipuncture. of.healthy.animals.constitutes.an.important.risk.of.exposure.to.pathogens..

.4..DENTAL.PROCEDURESDental.procedures.create.splashes.or.sprays.

of. saliva. and. blood. that. are. potentially. infec-tious.. There. is. also. the. potential. for. cuts. and.abrasions. from. dental. equipment. and. teeth..Veterinary.personnel.performing.the.dental.pro-cedure. and.anyone. in. range.of.direct. splashes.or. sprays. should. wear. protective. outerwear,.gloves,.and.facial.protection.86.In.1.study.in.hu-mans,.irrigation.of.the.oral.cavity.with.a.0.12%.chlorhexidine. solution. significantly. decreased.bacterial.aerosolization.87.

.5..RESUSCITATIONThe.urgent.nature.of.resuscitation.increases.

the. likelihood. that. breaches. in. infection. con-trol.will.occur..Barrier.precautions,.such.as.use.of. gloves. and. facial. protection,. should. be. ap-plied.to.prevent.exposure.to.zoonotic.infectious.agents.that.may.be.present..Never.blow.into.the.nose.or.mouth.of.an.animal.or.into.an.endotra-cheal.tube.for.purposes.of.resuscitation;.instead,.intubate.the.animal.and.use.a.manual.resuscita-tor.or.an.anesthesia.machine.or.ventilator.

.6..OBSTETRICSCommon. zoonotic. agents,. including. Bru-

cella.spp,.C burnetii,.and.Listeria.monocytogenes,.may. be. found. in. high. concentrations. in. the.birthing.fluids.of.aborting.or.parturient.animals.and.in.stillborn.fetuses.and.neonates.88.Gloves,.sleeves,.facial.protection,.and.impermeable.pro-tective.outerwear.should.be.used.as.needed.to.prevent.exposures.to.potentially.infective.mate-rials..Never.attempt.to.resuscitate.a.nonrespir-ing.neonate.by.blowing.directly.into.its.nose.or.mouth.

.7..NECROPSYNecropsy. is. a. high-risk. procedure. because.

of. potential. contact. with. infectious. agents. in.body.fluids.and.aerosols.and.on.contaminated.sharps.75. Nonessential. persons. should. not. be.present.during.necropsy.procedures..Veterinary.personnel.should.wear.gloves,.facial.protection,.and.impermeable.protective.outerwear.as.need-ed..In.addition,.cut-proof.gloves.should.be.used.to.prevent.sharps-associated.injuries..Respirato-


ry.tract.protection.and.environmental.controls.should.be.employed.when.band.saws.or.other.power.equipment.are.used..

.8..DIAGNOSTIC-SPECIMEN.HANDLINGFeces,.urine,.aspirates,.and.swabs.should.be.

handled. as. though. they. contained. infectious.organisms..Protective.outerwear.and.disposable.gloves. should. be. worn. when. handling. these.specimens..Discard.gloves.and.wash.hands.be-fore.touching.clean.items.(eg,.medical.records.or. telephones).. Eating. and. drinking. must. not.be.allowed.in.the.laboratory..

...C. ENVIRONMENTAL INFECTION CONTROL:.1..ISOLATION.OF.ANIMALS.WITH.INFECTIOUS.......................................................................DISEASES

A. single-purpose. isolation. room. is. recom-mended.for.the.care.and.housing.of.animals.with.potentially.communicable.diseases..A.designated.examination.room.that.can.be.easily.emptied.of.nonessential. equipment. and.cleaned.and.disin-fected.can.be.transformed.into.an.isolation.room..A.cage.may.be.brought. in. for. the.animal.. If.an.isolation. room. has. a. negative. pressure. air-han-dling.system,.the.air.should.be.exhausted.outside.of.the.building.away.from.animal.and.public.ac-cess.areas,.employee.break.areas,.and.air-intake.vents.4,89.Air.pressures.should.be.monitored.daily.while.in.use.

The.isolation.room.should.have.signage.in-dicating.that.the.animal.may.have.an.infectious.disease. and. detailing. what. precautions. should.be.taken.53.Access.to.the.room.should.be.limit-ed,.and.a.sign-in.sheet.should.be.used.to.moni-tor.all.people.entering.the.isolation.area.

Only.the.equipment.and.materials.needed.for.the.care.and.treatment.of.the.patient.should.be.kept.in.the.isolation.room..Items.intended.for.use.in.the.isolation.room.should.remain.there;.if.nec-essary,.replacement.items.should.be.procured.for.use.elsewhere.in.the.hospital..Items.in.the.isola-tion. area. should. be. disassembled,. cleaned,. and.disinfected. prior. to. removal.. Use. of. disposable.articles.minimizes.exposure.of.personnel.to.po-tentially.infective.materials..Potentially.contami-nated.materials.should.be.bagged.before.transport.within.the.practice.and.disinfected.or.disposed.of.according.to.their.level.of.hazard.53,84

Limited.data. are. available. regarding. the. ef-ficacy. of. shoe. covers. and. footbaths. for. infec-tion.control. in.veterinary. settings..When.shoe.or. boot. coverings. are. used,. personnel. should.be.trained.to.use,.remove,.and.dispose.of.them.properly.because.improper.use.or.disposal.may.increase. the. risk. of. exposure. to. pathogens..When.a.disinfectant.footbath.is.in.use,.it.should.be. placed. just. inside. the. door. of. the. isolation.area.so.that.personnel.step.through.it.before.de-parting.the.room.90.Footbath.disinfectant.should.be.changed.daily.or.when.visibly.dirty..

2..CLEANING.AND.DISINFECTION.OF.EQUIPMENT......AND.ENVIRONMENTAL.SURFACES

Environmental. surfaces. and. equipment.should.be.cleaned.and.disinfected.between.uses.

or. whenever. visibly. soiled.. Surfaces. in. areas.where.animals.are.housed,.examined,.or.treated.should. be. made. of. nonporous,. easily. cleaned.materials..During.cleaning,.adequate.ventilation.should.be.provided;.generation.of.dust.that.may.contain.pathogens.can.be.minimized.by.use.of.central.vacuum.units,.wet.mopping,.dust.mop-ping,.or.electrostatic.sweeping..Surfaces.may.be.lightly.sprayed.with.water.prior.to.mopping.or.sweeping..Facial.protection.and.control.of.splat-ter.can.minimize.exposure.to.aerosols.generated.by. brushing. during. cleaning. activities.. High-pressure. sprayers. may. aerosolize. and. dissemi-nate. infectious. small. particles,. and. their. use.should.be.limited.

Gross. contamination. must. be. removed. be-fore. disinfection. because. organic. material. de-creases.the.effectiveness.of.most.disinfectants.91.To.maximize.effectiveness,.disinfectants.should.be. used. according. to. manufacturers’. instruc-tions;.check.label.for.proper.dilution.and.contact.time..Personnel.engaged.in.cleaning.and.disin-fection.should.be. trained. in.safe.practices.and.provided.necessary.safety.equipment.according.to.the.product’s.material.safety.data.sheet..

Routine. dish. washing. of. food. and. water.bowls.is.adequate.for.hospitalized.patients.with.infectious.diseases,4.although.use.of.disposable.dishes.should.be.considered.for.animals.in.isola-tion..Toys,.litter.boxes,.and.other.miscellaneous.items.should.be.discarded.or.cleaned.and.disin-fected.between.patient.uses..Litter.boxes.should.be.cleaned.or.disposed.of.at.least.daily.by.a.non-pregnant. staff.member..Clean. items. should.be.kept.separate.from.dirty.items.

.3..HANDLING.OF.LAUNDRYAlthough.soiled.laundry.may.be.contaminat-

ed.with.pathogens,.the.risk.of.disease.transmis-sion.is.negligible.if.handled.correctly..Personnel.should. check. for. sharps.before. items. are. laun-dered..Gloves.and.protective.outerwear.should.be.worn.when.handling.soiled.laundry..Bedding.and.other. laundry. should.be.machine.washed.with.standard. laundry.detergent.and.machine.dried..To.prevent.cross-contamination,.separate.storage.and.transport.bins.should.be.used.for.clean.and.dirty. laundry.. If. soiled. clothing. is. laundered. at.home,.it.should.be.transported.in.a.sealed.plastic.bag.and.put.directly.into.a.washing.machine..

.4..DECONTAMINATION.AND.SPILL.RESPONSE. ...Spills.and.splashes.of.blood,.body.fluids,.or.potentially.infective.substances.should.be.imme-diately.sprayed.with.disinfectant.and.contained.with.absorbent.material.(eg,.paper.towels,.saw-dust,.or.cat.litter)..Personnel.should.wear.gloves.and. other. appropriate. protective. equipment.before. beginning. the. cleanup.. The. spilled. flu-ids.and.absorbent.material.should.be.picked.up.and. sealed. in. a. leak-proof.plastic.bag,. and. the.area.should.be.cleaned.and.disinfected..Animals.and.people.who.are.not.involved.in.the.cleanup.should.be.kept.away.from.the.area.until.disinfec-tion.is.completed.89


.5..VETERINARY.MEDICAL.WASTEMedical.waste.is.defined.and.regulated.at.the.

state.level.by.multiple.agencies.but.may.include.sharps,. tissues,. contaminated. materials,. and.dead.animals.84,92.The.AVMA.recommends.vol-untary.compliance.with.the.OSHA.Bloodborne.Pathogen. Standard93. regarding. medical. waste..It. is.beyond.the.scope.of.this.Compendium.to.describe.veterinary.medical.waste.management.in.detail;.for.guidance,.local.or.state.health.de-partments. and. municipal. governments. should.be.consulted..Additional.information.regarding.state. regulating. agencies. is. available. from. the.Environmental.Protection.Agency.94.

.6..RODENT.AND.VECTOR.CONTROL.Many. important. zoonotic. pathogens. are.

transmitted.by. insect. vectors.or. rodents.. Inte-grated. pest. management. is. a. comprehensive.approach.used.to.prevent.and.control.pests.95,96.Measures. included. in. integrated. pest. manage-ment.are.as.follows:•.. Seal. potential. entry. and. exit. points. into.

buildings;. common. methods. include. the.use.of.caulk,.steel.wool,.or.metal.lath.under.doors.and.around.pipes.

•.. Store. food. and. garbage. in. metal. or. thick-plastic.containers.with.tight.lids.

•.. Dispose.of.food.waste.promptly.•.. Eliminate.potential.rodent.nesting.sites.(eg,.

clutter.or.hay.and.food.storage).•.. Maintain. rodent. traps. in. the. facility. and.

check.daily.•.. Remove.sources.of.standing.water.(eg,.emp-

ty.buckets,.tires,.and.clogged.gutters).from.around. the. building. to. reduce. potential.mosquito.breeding.sites.

•.. Install.and.maintain.window.screens.to.prevent.entry.of.insects.and.rodents.into.buildings.

Additional. measures. may. be. warranted. for.control. of. specific. pests.. For. example,. bats.should. be. excluded. from. hospital. barns. and.veterinary. facilities.. Veterinary. facility. manag-ers.may.wish.to.contact.a.pest.control.company.for.additional.guidance..

.7..OTHER.ENVIRONMENTAL.CONTROLSIt. is. important. to. designate. staff. areas. for.

eating,. drinking,. or. smoking. that. are. separate.from.patient.care.areas..Separate.and.appropri-ately. labeled. refrigerators. should. be. used. for.food.for.humans,.food.for.animals,.and.biolog-ics..Dishware.for.human.use.should.be.cleaned.and.stored.away.from.animal-care.areas..

IV. EMPLOYEE HEALTH A. GENERAL:

Veterinary.practice.managers.should.promote.infection.control.as.part.of.a.comprehensive.em-ployee.health.program..Senior.management.sup-port.is.essential.for.staff.compliance.with.policies.and.procedures.97,98.

In.addition.to.maintaining.up-to-date.emer-gency.contact.information,.veterinary.practices.

should.maintain. staff. records. including.details.of. vaccinations,. rabies. virus. antibody. titers,.and. exposures. to. infectious. organisms. to. ex-pedite. care. following. occupational. health. in-cidents.99,100. Employee. health. records. should.be. collected.on.a. voluntary.basis,.with. a. clear.understanding.that.confidentiality.will.be.main-tained..Health-related.issues.that.may.influence.employees’.work.duties.should.be.documented.in. personnel. files.. Employees. should. inform.their. supervisor. of. changes. in. health. status,.such. as. pregnancy,. that. may. affect. work. du-ties.. Veterinary. personnel. should. inform. their.health-care.provider. that. their.work.duties. in-volve.animal.contact.

. 1..EMPLOYEE.VACCINATION.POLICIES.AND..........RECORD.KEEPING.

............ a..Rabies.Veterinary. personnel. who. have. contact.

with.animals.should.be.offered.preexposure.vaccination.in.accordance.with.recommen-dations.of.the.ACIP.101.Preexposure.vaccina-tion.consists.of.3.doses.of. a.human. rabies.vaccine;.after.the.first.dose.(given.on.day.0),.subsequent. doses. are. administered. on. day.7.and.day.21.or.28..Following.preexposure.vaccination,. the. ACIP. guidelines. recom-mend. that. rabies. virus. antibody. titers. be.checked.every.2.years.for.individuals.in.the.frequent.risk.category,.which.includes.most.veterinary. personnel. in. the. United. States..Preexposure.vaccination.against.rabies.does.not.eliminate.the.need.for.appropriate.treat-ment.following.a.known.rabies.virus.expo-sure,.but. it.does.simplify. the.postexposure.treatment.regimen.(2.doses.of.vaccine.with-out.administration.of.human.rabies.immune.globulin. for. preexposure-vaccinated. indi-viduals. vs. 5. doses. of. vaccine. with. admin-istration.of.human.rabies.immune.globulin.for. individuals. who. were. not. previously.vaccinated)..In.addition,.preexposure.vacci-nation.may.protect.against.unrecognized.ra-bies.exposures.or.when.postexposure.treat-ment.is.delayed.101

.......b..TetanusVeterinary.personnel.should.be.vaccinat-

ed.against. tetanus.every.10.years. in.accor-dance.with.ACIP.recommendations.102.

.......c..InfluenzaVeterinary. personnel,. especially. those.

working.with.poultry.or.swine,.are.encour-aged. to. receive. the. current. influenza. virus.vaccine.. This. is. intended. to. minimize. the.small. possibility. that. dual. infection. of. an.individual.with.human.and.either. avian.or.swine.influenza.viruses.could.result.in.a.new.strain.of.influenza.virus.103–106.

2..MANAGEMENT.AND.DOCUMENTATION.OF..............EXPOSURE.INCIDENTS

Display.incident.response.procedures.prom-inently.. First. aid. should. be. readily. available,.and. personnel. should. be. trained. to. recognize.


and.respond.to.emergency.situations..Following.the.administration.of.first.aid,.strongly.encour-age. affected.persons. to. contact. an. appropriate.health-care.provider..

Injuries. or. potential. exposures. to. zoonotic.pathogens.should.be.reported,.investigated,.and.documented..Practice.managers.should.develop.policies.that.encourage.reporting.100.An.incident.report.form,.such.as.OSHA.form.300,.should.in-clude.details.as.follow:•. Date,.time,.and.location.of.the.incident.•. Name.of.person.injured.or.exposed.•. Names.of.other.persons.present.•. Description.of.the.incident.•. Whether.or.not.a.health-care.provider.was.

consulted.•. Status.of. the.animal. involved.(vaccination.

status,.clinical.condition,.and.any.diagnos-tic.test.results.[or.tests.pending]).

•. Documentation. of. any. report. to. public.health.authority.

•. Plans.for.follow-up.

Practice. managers. should. contact. their. lo-cal.or.state.health.department.to.inquire.about.mandatory.reporting.of.bite.incidents.and.zoo-notic.disease.exposures..

.3..STAFF.TRAINING.AND.EDUCATION.Staff. training.at. the.beginning.of.employ-

ment. and. at. least. annually. is. an. essential.component. of. an. effective. employee. health.program.. Training. should. emphasize. infec-tion. control. practices,. the. potential. for. zoo-notic. disease. exposure,. hazards. associated.with. work. duties,. and. injury. prevention.. It.should. also. include. instruction. in. animal.handling,.restraint,.and.behavioral.cue.recog-nition.. Additional. in-service. training. should.be. provided. as. recommendations. change. or.as. problems. with. infection. control. policies.are. identified.. Staff. participation. in. training.should.be.documented..

B. IMMUNOCOMPROMISED PERSONNEL:Immunocompromised. personnel. are. more.

susceptible. to. infection. with. zoonotic. agents.and. more. likely. to. develop. serious. complica-tions. from. zoonotic. infections.107. Immune. re-sponses.may.be.suppressed.by.conditions,. in-cluding.HIV/AIDS,.diabetes.mellitus,.asplenia,.pregnancy,.certain.malignancies,.or.congenital.abnormalities..Certain. treatments. (eg,. admin-istration. of. corticosteroids,. chemotherapeutic.agents,.and.immunosuppressive.drugs).and.ra-diation. therapy. may. also. suppress. immunity..Potentially. immunocompromised. personnel.and. their. supervisors. should. be. aware. that.workplace.activities.with.a.higher.risk.of.expo-sure.to.zoonotic.pathogens.include.processing.of. laboratory. samples. and.direct. patient. care,.especially. care. of. high-risk. animals.66. These.include.animals.that.are.young,.parturient,.un-vaccinated,. stray. or. feral,. fed. raw. meat. diets,.or. housed. in. crowded. conditions. (eg,. shel-

ters);. animals. with. internal. or. external. para-sites;. wildlife;. reptiles. and. amphibians;. and.exotic.or.nonnative.species.66.

Although. data. regarding. the. risks. of. zoo-notic. infection. for. HIV-infected. persons. em-ployed.in.veterinary.settings.are.limited,.there.are.none. that. justify. their. exclusion. from. the.veterinary. workplace.108. Risk. of. exposure. to.zoonotic. pathogens. in. the. workplace. can. be.mitigated. with. appropriate. infection. control.measures.108.

During. pregnancy,. physiologic. suppres-sion.of.cell-mediated.immunity.occurs,.which.increases. a. woman’s. susceptibility. to. certain..infectious. diseases,. such. as. toxoplasmosis,.lymphocytic. choriomeningitis,. brucellosis,.listeriosis,.and.psittacosis.109.Vertical.transmis-sion. of. certain. zoonotic. agents. may. result. in.spontaneous. abortion,. stillbirth,. premature.birth,.or.congenital.anomalies..

Employees. with. immune. dysfunction. should.discuss.their.health.status.with.the.practice.man-ager. so. appropriate. workplace. accommodations.can.be.made.. It.may.be.advisable. to.consult. the.employee’s. health-care. provider. or. an. infection.control,.public.health,.or.occupational.health.spe-cialist.110.Employers.must.abide.by.state.and.fed-eral. laws. that. protect. pregnant. women. and. per-sons.with.disabilities..Employees.must.be.assured.that.confidential.information.will.not.be.disclosed.to.others..

V. CREATING A WRITTEN INFECTION CONTROL PLANAll.veterinary.practices.should.have.a.written.in-

fection.control.plan.that.is.reviewed.and.updated.at.least. annually.. A. model. infection. control. plan. that.can.be.tailored.to.individual.practice.needs.is.avail-able.(Appendix.3).

Effective. infection. control. plans. should. do. the.following:•. Reflect. the. principles. of. infection. control. out-

lined.in.this.Compendium.•. Be.specific.to.the.facility.and.practice.type.•. Be.flexible.so. that.new.issues.can.be.addressed.

easily.and.new.knowledge.incorporated.•. Provide.explicit.and.well-organized.guidance.•. Clearly.describe. the. infection. control. responsi-

bilities.of.staff.members.•. Include.a.process.for.the.evaluation.of.infection.

control.practices.•. Provide. contact. information,. resources,. and.

references. (eg,. reportable. disease. list,. public.health. contacts,. local. rabies. codes. and. envi-ronmental. health. regulations,. OSHA. require-ments,.Web.sites.of.interest,.and.client.educa-tion.materials).

....A. INFECTION CONTROL PERSONNEL:Designated. staff. members. should. be. respon-

sible. for. development. and. implementation. of.infection. control. policies,. monitoring. compli-ance,. maintenance. of. records,. and. management.of.workplace.exposures.and.injury.incidents..Ad-ditional.personnel.should.be.assigned.responsibil-


ity.for.completion.of.infection.control.activities.in.support.of.the.plan.

B. COMMUNICATING AND UPDATING THE INFECTION CONTROL PLAN:.

.1..AVAILABILITY.Copies.of.the.infection.control.plan.and.re-

source.documents. should.be.kept. at. locations.that.are.readily.accessible.to.all.staff,.including.reception,. administrative,. animal-care,. house-keeping,.and.veterinary.medical.personnel..

.2..LEADERSHIP.Senior.and.managerial.personnel.should.set.

the.standard.for.infection.control.practices,.em-phasize. the. importance.of. infection.control. to.other. staff,. and.reference. the. infection.control.plan.in.daily.activities.

.3..NEW.STAFFNew.staff.members.should.be.given.a.copy.

of.the.infection.control.plan..Detailed.training.on.the.practice’s. infection.control.policies.and.procedures,. employee. vaccination. recommen-dations,.and.incident.reporting.should.be.pro-vided..Receipt.of. the.plan.and.training.should.be.documented.for.each.employee..

.4..CONTINUING.EDUCATION.Infection. control. procedures. should. be. re-

viewed.at. least.annually.at. staff.meetings,.and.regular. continuing. education.on. zoonotic.dis-ease.topics.should.be.encouraged..

.5..REVIEW.AND.REVISION.A.designated.staff.person.should.review.and.

revise. the. infection. control. plan. when. new. in-formation.becomes.available.or.clinical.practices.change..Revisions.should.be.shared.with.all.staff.members,. and. all. copies. of. the. plan. should. be.updated.

.6..COMPLIANCEA.designated.staff.person.should.ensure.that.

infection.control.policies.and.protocols.are.car-ried.out.consistently.and.correctly.and.that.cor-rective. measures. and. employee. retraining. are.instituted.when.deficiencies.are.identified..

VI. REFERENCES1... Langley.RL,.Pryor.WH,.O’Brien.KF..Health.hazards.among.

veterinarians:.a.survey.and.review.of.the.literature..J Agro-medicine.1995;2:23–52.

2... Snow.J,.Rice.J..Infection.control.in.veterinary.clinics..North-west Public Health.2005;Fall/Winter:22–23.

3... Wright.JG,.Jung.S,.Holman.RC,.et.al..Infection.control.prac-tices. and. zoonotic. disease. risks. among. veterinarians. in. the.United.States..J Am Vet Med Assoc.2008;232:1863–1872..

4... Siegel. JD,. Rhinehart. E,. Jackson. M,. et. al.. 2007. guideline.for.isolation.precautions:.preventing.transmission.of.infec-tious.agents.in.healthcare.settings,.June.2007..Available.at:.www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007.pdf..Accessed.Apr.22,.2008..

5... CDC..Update:.multistate.outbreak.of.monkeypox—Illinois,.Indiana,. Kansas,. Missouri,. Ohio,. and. Wisconsin,. 2003..Morb Mortal Wkly Rep 2003;52:642–646..

6... Croft.DR,.Sotir.MJ,.Williams.CJ,.et.al..Occupational.risks.during.a.monkeypox.outbreak,.Wisconsin,.2003..Emerg In-fect Dis.2007;13:1150–1157..

7... Marano.N,.Pappaioanou.M..Historical,.new,.and.reemerg-ing.links.between.human.and.animal.health..Emerg Infect Dis.2004;10:2065–2066..

8... Taylor.LH,.Latham.SM,.Woolhouse.ME..Risk.factors.for.hu-man.disease.emergence..Philos Trans R Soc Lond B Biol Sci 2001;356:983–989..

9... Wright,.JG,.Tengelsen.LA,.Smith.KE,.et.al..Multi-drug.re-sistant. Salmonella. Typhimurium. in. four. animal. facilities..Emerg Infect Dis.2005;11:1235–1241..

10... Cherry.B,.Burns.A,.Johnson.GS,.et.al..Salmonella.Typhimuri-um.outbreak.associated.with.veterinary.clinic..Emerg Infect Dis.2004;10:2249–2251..

11... Bender.JB,.Tsukayama.DT..Horses.and.the.risk.of.zoonotic.infections.. Vet Clin North Am Equine Pract. 2004;20:643–653..

12... Levine.JF,.Levy.MG,.Walker.RL,.et.al..Cryptosporidiosis.in.veterinary. students.. J Am Vet Med Assoc 1988;193:1413–1414.

13... Anderson. BC,. Donndelinger. T,. Wilkins. RM,. et. al.. Cryp-tosporidiosis. in. a. veterinary. student.. J Am Vet Med Assoc.1982;180:408–409.

14... Reif.JS,.Wimmer.L,.Smith.JA,.et.al..Human.cryptosporidio-sis.associated.with.an.epizootic.in.calves..Am J Public Health.1989;79:1528–1530..

15... Pohjola.S,.Oksanen.H,. Jokipii.L,.et.al..Outbreak.of.cryp-tosporidiosis.among.veterinary.students..Scand J Infect Dis.1986;18:173–178.

16... Preiser.G,.Preiser.L,.Madeo.L..An.outbreak.of.cryptospo-ridiosis.among.veterinary.science.students.who.work.with.calves..J Am Coll Health.2003;51:213–215.

17... Gage.KL,.Dennis.DT,.Orloski.KA,.et.al..Cases.of.cat-asso-ciated.human.plague.in.the.Western.US,.1977–1998..Clin Infect Dis.2000;30:893–900.

18... Dunstan.RW,.Reimann.KA,.Langham.RF..Feline. sporotri-chosis..In:.Zoonosis updates from the Journal of the American Veterinary Medical Association. 2nd. ed.. Schaumburg,. Ill:.American.Veterinary.Medical.Association,.1995;79–82.

19... Dunstan.RW,.Langham.RF,.Reimann.KA,.et.al..Feline.spo-rotrichosis:.a.report.of.five.cases.with.transmission.to.hu-mans..J Am Acad Dermatol.1986;15:37–45.

20... Nusbaum. BP,. Gulbas. N,. Horwitz. SN.. Sporotrichosis. ac-quired.from.a.cat..J Am Acad Dermatol.1983;8:386–391.

21... Reed.KD,.Moore.FM,.Geiger.GE,.et.al..Zoonotic.transmis-sion. of. sporotrichosis:. case. report. and. review.. Clin Infect Dis.1993;16:384–387..

22... Clinkenbeard. KD.. Diagnostic. cytology:. sporotrichosis..Compend Contin Educ Pract Vet.1991;13:207–211.

23... Baptiste.KE,.Williams.K,.Williams.NJ,.et.al..Methicillin-re-sistant.staphlococci.in.companion.animals..Emerg Infect Dis.2005;11:1942–1944.

24... Bender.JB,.Torres.SMF,.Gilbert.SM,.et.al..Isolation.of.methi-cillin-resistant. Staphylococcus aureus. from. a. non-healing.abscess.in.a.cat..Vet Rec.2005;157:388–389.

25... Weese. JS,. Dick. H,. Willey. BM,. et. al.. Suspected. transmis-sion.of.methicillin-resistant.Staphylococcus aureus.between.domestic.pets.and.humans.in.veterinary.clinics.and.in.the.household..Vet Microbiol 2006;115:148–155..

26... O’Mahony.R,.Abbott.Y,.Leonard.FC,.et.al..Methicillin-re-sistant. Staphylococcus aureus. (MRSA). isolated. from. ani-mals. and. veterinary. personnel. in. Ireland.. Vet Microbiol.2005;109:285–296.

27... Hanselman. BA,. Kruth. SA,. Rousseau. J,. et. al.. Methicillin-resistant. Staphylococcus aureus. colonization. in. veterinary.personnel..Emerg Infect Dis.2006;12:1933–1938.

28... Wulf. M,. Van. Nes. A,. Eikelenboom-Boskamp. A,. et. al..Methicillin-resistant. Staphylococcus aureus. in. veterinary.doctors. and. students,. the. Netherlands.. Emerg Infect Dis.2006;12:1939–1941.

29... Weese.JS,.Rousseau.J,.Traub-Dargatz.JL,.et.al..Community-associated. methicillin-resistant. Staphylococcus aureus. in.horses.and.humans.who.work.with.horses.. J Am Vet Med Assoc.2005;226:580–583.

30... Weese. JS,. Caldwell. F,. Willey. BM,. et. al.. An. outbreak. of.methicillin-resistant. Staphylococcus aureus. skin. infections.resulting.from.horse.to.human.transmission.in.a.veterinary.hospital..Vet Microbiol 2006;114:160–164..

31... Leonard.FC,.Abbott.Y,.Rossney.A,.et.al..Methicillin-resis-


tant. Staphylococcus aureus. isolated. from.a. veterinary. sur-geon.and.five.dogs.in.one.practice..Vet Rec.2006;158:155–159.

32... Voss. A,. Loeffen. F,. Bakker. J,. et. al.. Methicillin-resistant.Staphylococcus aureus. in. pig. farming.. Emerg Infect Dis.2005;11:1965–1966.

33... Juhasz-Kaszanyitzky. E,. Janosi. S,. Somogyi. P,. et. al.. MRSA.transmission.between.cows.and.humans..Emerg Infect Dis.2007;13:630–631.

34... Palmer.SR,.Andrews.BE,.Major.R..A.common-source.out-break. of. ornithosis. in. veterinary. surgeons.. Lancet. 1981;.2:798–799.

35... Heddema.ER,.van.Hannen.EJ,.Duim.B,.et.al..An.outbreak.of.psittacosis.due.to.Chlamydophila psittaci.genotype.A.in.a.veterinary.teaching.hospital..J Med Microbiol.2006;55:1571–1575.

36... Vanrompay.D,.Harkinezhad.T,.Van.de.Walle.M,.et.al..Chla-mydophila psittaci.transmission.from.pet.birds.to.humans..Emerg Infect Dis.2007;13:1108–1110.

37... Gosbell.IB,.Ross.AD,.Turner.IB..Chlamydia psittaci.infection.and.reinfection. in.a.veterinarian..Aust Vet J.1999;77:511–513.

38... Constable.PJ,.Harrington.JM..Risks.of.zoonoses.in.a.veteri-nary.service..Br Med J (Clin Res Ed).1982;284:246–248..

39... Landercasper.J,.Cogbill.TH,.Strutt.PJ,.et.al..Trauma.and.the.veterinarian..J Trauma 1988;28:1255–1259..

40... Gabel.CL,.Gerberich.SG..Risk.factors.for.injury.among.vet-erinarians..Epidemiology.2002;13:80–86.

41... Jeyaretnam.J,.Jones.H,.Phillips.M..Disease.and.injury.among.veterinarians..Aust Vet J 2000;78:625–629.

42... Nienhaus.A,.Skudlik.C,.Seidler.A..Work-related.accidents.and.occupational.diseases. in.veterinarians.and.their.staff..Int Arch Occup Environ Health.2005;78:230–238.

43... Talan. DA,. Citron. DM,. Abrahamian. FM,. et. al.. Bacterio-logic.analysis.of. infected.dog.and.cat.bites..N Engl J Med.1999;340:85–92.

44... Le.Moal.G,.Landron.C,.Grollier.G,.et.al..Meningitis.due.to.Capnocytophaga canimorsus.after.receipt.of.a.dog.bite:.case.report.and.review.of.the.literature..Clin Infect Dis 2003;36:e42–e46.

45... Shukla.SK,.Paustian.DL,.Stockwell.PJ,.et.al..Isolation.of.a. fastidious.Bergeyella. species. associated.with.cellulitis.after.a.cat.bite.and.a.phylogenetic.comparison.with.Ber-geyella zoohelcum.strains..J Clin Microbiol.2004;42:290–293.

46... Kaiser. RM,. Garman. RL,. Bruce. MG,. et. al.. Clinical. sig-nificance. and. epidemiology. of. NO-1,. an. unusual. bacte-rium. associated. with. dog. and. cat. bites.. Emerg Infect Dis.2002;8:171–174.

47... Hara.H,.Ochiai.T,.Morishima.T,.et.al..Pasteurella canis.os-teomyelitis. and. cutaneous. abscess. after. a. domestic. dog.bite..J Am Acad Dermatol.2002;46(suppl.5):s151–s152..

48... Poole.AG,.Shane.SM,.Kearney.MT,.et.al..Survey.of.occupa-tional.hazards.in.companion.animal.practices..J Am Vet Med Assoc.1998;212:1386–1388.

49... Poole.AG,.Shane.SM,.Kearney.MT,.et.al..Survey.of.occupa-tional.hazards.in.large.animal.practices..J Am Vet Med Assoc 1999;215:1433–1435.

50... Hafer.AL,.Langley.RL,.Morrow.WEM,. et. al..Occupation-al. hazards. reported. by. swine. veterinarians. in. the. United.States..J Swine Health Prod.1996;4:128–141.

51... Wilkins. JR,. Bowman. ME.. Needlestick. injuries. among. fe-male.veterinarians:.frequency,.syringe.contents.and.side-ef-fects..Occup Med.1997;47:451–457.

52... Ramsey.DT..Blastomycosis.in.a.veterinarian.(lett)..J Am Vet Med Assoc.1994;205:968..

53... Weese.JS..Barrier.precautions,.isolation.protocols,.and.per-sonal. hygiene. in. veterinary. hospitals.. Vet Clin North Am Equine Pract.2004;20:543–559..

54... Hannah.HW..A.veterinarian’s. liability. to.employees.. J Am Vet Med Assoc.1994;204:361–362.

55... Smith.R..Controlling.workers’. compensation. losses.. J Am Vet Med Assoc.1996;209:526.

56... Lenhart.SW,.Seitz.T,.Trout.D,.et.al..Issues.affecting.respira-

tor.selection.for.workers.exposed.to.infectious.aerosols:.em-phasis.on.healthcare.settings..Appl Biosafety.2004;9:20–36.

57... Acha.PN,.Szyfres.B..Q.fever..In:.Zoonoses and communicable diseases common to man and animals. Volume II. Chlamydio-ses, rickettsioses, and viroses..3rd.ed..Washington,.DC:.Pan.American.Health.Organization,.2003;16–27.

58... Tissot-Dupont. H,. Amadei. MA,. Nezri. M,. et. al.. Wind.in. November,. Q. Fever. in. December.. Emerg Infect Dis.2004;10:1264–1269.

59... McQuiston.JH,.Childs.JE..Q.fever.in.humans.and.animals.in.the.United.States..Vector Borne Zoonotic Dis.2002;2:179–191.

60... Nation.PN,.Fanning.EA,.Hopf.HB,.et.al..Observations.on.animal. and. human. health. during. the. outbreak. of. Myco-bacterium bovis. in.game. farm.wapiti. in.Alberta..Can Vet J 1999;40:113–117.

61... Boyce.JM,.Pittet.D..Guideline.for.hand.hygiene.in.health-care.settings:.recommendations.of.the.Healthcare.Infection.Control. Practices. Advisory. Committee. and. the. HICPAC/SHEA/APIC/IDSA.Hand.Hygiene.Task.Force..Morb Mortal Wkly Rep Recomm Rep 2002;51:1–48..

62... Larson. EL.. APIC. guideline. for. handwashing. and. hand.antisepsis. in. health. care. settings.. Am J Infect Control 1995;23:251–269..

63... Ayliffe.GA,.Babb.JR,.Quoraishi.AH..A.test.for.hygienic.hand.disinfection..J Clin Pathol.1978;31:923–928.

64... Steere. AC,. Mallison. GF.. Handwashing. practices. for. the.prevention. of. nosocomial. infections.. Ann Intern Med.1975;83:683–690..

65... Lin. CM,. Wu. FM,. Kim. HK,. et. al.. A. comparison. of. hand.washing. techniques. to. remove. Escherichia coli. and. cali-civiruses. under. natural. or. artificial. nails.. J Food Prot.2003;66:2296–2301.

66... National.Association.of.State.Public.Health.Veterinarians..Compendium. of. measures. to. prevent. disease. associated.with.animals.in.public.settings,.2007..Available.at:.www.nasphv.org/Documents/AnimalsInPublicSettings.pdf...Accessed.Apr.22,.2008..

67... Widmer.AF,.Dangel.M..Alcohol-based.handrub:.evaluation.of.technique.and.microbiological.efficacy.with.internation-al.infection.control.professionals..Infect Control Hosp Epide-miol.2004;25:207–209.

68... Sickbert-Bennett. EE,. Weber. DJ,. Gergen-Teague. MF,. et. al..Comparative.efficacy.of.hand.hygiene.agents.in.the.reduction.of.bacteria.and.viruses..Am J Infect Control.2005;33:67–77.

69... Gehrke.C,.Steinmann.J,.Goroncy-Bermes.P..Inactivation.of.feline.calicivirus,.a. surrogate.of.norovirus.(formerly.Nor-walk-like.viruses),.by.different.types.of.alcohol.in.vitro.and.in.vivo..J Hosp Infect.2004;56:49–55.

70... Goldmann.DA..The.role.of.barrier.precautions.in.infection.control..J Hosp Infect.1991;18:515–523.

71... Olsen.RJ,.Lynch.P,.Coyle.MB,.et.al..Examination.gloves.as.barriers. to.hand.contamination. in.clinical.practice..JAMA.1993;270:350–353.

72... Doebbeling.BN,.Pfaller.MA,.Houston.AK,.et.al..Removal.of.nosocomial.pathogens.from.the.contaminated.glove:.impli-cations. for.glove.reuse.and.handwashing..Ann Intern Med.1988;109:394–398.

73... Patterson.JE,.Vecchio.J,.Pantelick.EL,.et.al..Association.of.contaminated. gloves. with. transmission. of. Acinetobacter calcoaceticus.var..anitratus. in.an. intensive.care.unit..Am J Med.1991;91:479–483.

74... National.Institute.of.Occupational.Safety.and.Health..Pre-venting. allergic. reactions. to. natural. rubber. latex. in. the.workplace..DHHS.(NIOSH).publication.No..97-135..Avail-able.at:.www.cdc.gov/niosh/latexalt.html..Accessed.Feb.1,.2008.

75... Bemis. DA,. Craig. LE,. Dunn. JR.. Salmonella. transmission.through.splash.exposure.during.a.bovine.necropsy..Food-borne Pathog Dis.2007;4:387–390.

76... National. Institute. of. Occupational. Safety. and. Health..NIOSH-approved.disposable.particulate.respirators.(filter-ing.facepieces)..Available.at:.www.cdc.gov/niosh/npptl/top-ics/respirators/disp_part/..Accessed.Apr.22,.2008..


77... US.Department.of.Labor,.Occupational.Safety.and.Health.Administration.. Respiratory. protection. OSHA. standards..Available. at:. www.osha.gov/SLTC/respiratoryprotection/standards.html..Accessed.Apr.22,.2008.

78... Belkin.NL..Use.of.scrubs.and.related.apparel.in.health.care.facilities..Am J Infect Control 1997;5:401–404.

79... Belkin.NL..Home.laundering.of.soiled.surgical.scrubs:.sur-gical.site.infections.and.the.home.environment..Am J Infect Control.2001;29:58–64.

80... Sheldon.CC,.Sonsthagen.T,.Topel.JA..Restraint.principles..In:. Animal restraint for veterinary professionals.. St. Louis:.Mosby.Elsevier,.2006;1–6..

81... CDC..Guidelines.and.resources,.Monkeypox.infections.in.animals:.updated.interim.guidance.for.veterinarians..Avail-able. at:.www.cdc.gov/ncidod/monkeypox/animalguidance.htm..Accessed.Feb.1,.2008.

82... Seibert.PJ. Jr..Hazards. in. the.hospital.. J Am Vet Med Assoc.1994;204:352–360.

83... Grizzle.WE,.Fredenburgh.J..Avoiding.biohazards.in.medi-cal,.veterinary,.and.research.laboratories..Biotech Histochem.2001;76:183–206.

84... Brody.MD..Safety.in.the.veterinary.medical.workplace.envi-ronment..Vet Clin North Am Small Anim Pract 1993;23:1071–1084..

85... Cornell. Center. for. Animal. Resources. and. Education..CARE711.01. sharps. precautions.. Available. at:. www.re-search.cornell.edu/care/CARE711.pdf.. Accessed. Apr. 22,.2008..

86... Holmstrom.SE,.Bellows.J,.Colmery.B,.et.al..AAHA.dental.care. guidelines. for. dogs. and. cats.. J. Am Anim Hosp Assoc.2005;41:277–283.

87... Logothetis. DD,. Martinez-Welles. JM.. Reducing. bacterial.aerosol.contamination.with.a.chlorhexidine.gluconate.pre-rinse..J Am Dent Assoc.1995;126:1634–1639.

88... Heymann.DL..Brucellosis,.Q.fever,.listeriosis..In:.Heymann.DL,.ed..Control of communicable diseases manual..18th.ed..Washington,. DC:. American. Public. Health. Association,.2004;75–78,.434–438,.309–312.

89... CDC.. Guidelines. for. environmental. infection. control. in.health-care. facilities:. recommendations. of. CDC. and. the.Healthcare. Infection.Control.Practices.Advisory.Commit-tee.(HICPAC)..Morb Mortal Wkly Rep Recomm Rep 2003;52:.1–42..

90... Morley.PS,.Morris.SN,.Hyatt.DR,.et.al..Evaluation.of. the.efficacy.of.disinfectant.footbaths.as.used.in.veterinary.hos-pitals..J Am Vet Med Assoc 2005;226:2053–2058.

91... Dwyer.RM..Environmental.disinfection. to.control. equine.infectious. diseases.. Vet Clin North Am Equine Pract.2004;20:531–542.

92... Brody. MD.. AVMA. guide. for. veterinary. medical. waste.management. (Erratum. published. in. J Am Vet Med Assoc.1989;195:1130)..J Am Vet Med Assoc.1989;195:440–452.

93... US.Department.of.Labor,.Occupational.Safety.and.Health.Administration..Occupational.safety.and.health.standards:.toxic. and. hazardous. substances.. 1910.1030:. bloodborne.pathogens.. Available. at:. www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051..Accessed.Feb.1,.2008.

94... US.Environmental.Protection.Agency..Medical.waste..Avail-able. at:. www.epa.gov/epaoswer/other/medical.. Accessed.Apr.22,.2008..

95... Kogan.M..Integrated.pest.management:.historical.perspec-tives. and.contemporary.developments..Annu Rev Entomol.1998;43:243–270.

96... Peter.RJ,.Van.den.Bossche.P,.Penzhorn.BL,.et.al..Tick,.fly,.and.mosquito.control—lessons.from.the.past,.solutions.for.the.future..Vet Parasitol.2005;132:205–215..

97... Gershon.RRM,.Karkashian.CD,.Grosch.JW,.et.al..Hospital.

safety.climate.and.its.relationship.with.safe.work.practic-es. and.workplace. exposure. incidents..Am J Infect Control.2000;28:211–221.

98... Institute. for.Healthcare. Improvement..How-to.guide:. im-proving. hand. hygiene,. a. guide. for. improving. practices.among.health.care.workers..Available.at:.www.ihi.org..Ac-cessed.Apr.22,.2008..

99... Bolyard.EA,.Tablan.OC,.Williams.WW,.et.al..Guideline.for.infection.control.in.health.care.personnel,.1998..Am J Infect Control.1998;26:289–354..

100...Herwaldt. LA,. Pottinger. JM,. Carter. CD,. et. al.. Exposure.workups..Infect Control Hosp Epidemiol.1997;18:850–871..

101...CDC..Human.rabies.prevention—United.States,.2008:.rec-ommendations.of.the.Advisory.Committee.on.Immuniza-tion.Practices.(ACIP)..Morb Mortal Wkly Rep Recomm Rep.2008;57:1–28.

102...CDC..Immunization.of.health-care.workers:.recommenda-tions.of. the.Advisory.Committee.on. Immunization.Prac-tices.(ACIP).and.the.Hospital. Infection.Control.Practices.Advisory. Committee. (HICPAC).. Morb Mortal Wkly Rep Recomm Rep.1997;46:1–44.

103...CDC..Interim.guidance.for.protection.of.persons.involved.in. U.S.. avian. influenza. outbreak. disease. control. and.eradication. activities,. 2006.. Available. at:. www.cdc.gov/flu/avian/professional/protect-guid.htm..Accessed.Apr.22,.2008.

104...Gray.GC,.Trampel.DW,.Roth.JA..Pandemic.influenza.plan-ning:. shouldn’t. swine. and. poultry. workers. be. included?.Vaccine.2007;25:4376–4381.

105...Myers.KP,.Setterquist.SF,.Capuano.AW,.et.al..Infection.due.to.3.avian.influenza.subtypes.in.United.States.veterinarians..Clin Infect Dis.2007;45:4–9.

106...Myers.KP,.Olsen.CW,.Setterquist.SF,.et.al..Are.swine.work-ers.in.the.United.States.at.increased.risk.of.infection.with.zoonotic.influenza.virus?.Clin Infect Dis.2006;42:14–20..

107...Trevejo. RT,. Barr. MC,. Robinson. RA.. Important. emerging.bacterial.zoonotic.infections.affecting.the.immunocompro-mised..Vet Res.2005;36:493–506.

108...CDC.. Guidelines. for. preventing. opportunistic. infections.among.HIV-infected.persons—2002:. recommendations.of.the.U.S..Public.Health.Service.and.the.Infectious.Diseases.Society. of. America.. Morb Mortal Wkly Rep Recomm Rep 2002;51:1–52.

109...Moore.RM,.Davis.YM,.Kaczmarek.RG..An.overview.of.occu-pational.hazards.among.veterinarians,.with.particular.refer-ence.to.pregnant.women..Am Ind Hyg Assoc J.1993;54:113–120.

110...Grant.S,.Olsen.CW..Preventing.zoonotic.diseases.in.immu-nocompromised.persons:.the.role.of.physicians.and.veteri-narians..Emerg Infect Dis.1999;5:159–163.

111...Acha. PN,. Szyfres. B.. Zoonoses and communicable diseases common to man and animals..3rd.ed..Washington,.DC:.Pan.American.Health.Organization,.2003.

112...CDC..Healthy.Pets.Healthy.People.Web.site..Available.at:.www.cdc.gov/healthypets/browse_by_diseases.htm.. Ac-cessed.Apr.22,.2008.

113...Kahn.CM,.Line.SL,.eds..The Merck veterinary manual..9th.ed..Whitehouse.Station,.NJ:.Merck.and.Co,.2005.

114...CDC.. Nationally. notifiable. infectious. diseases.. United.States.2008..Available. at:.www.cdc.gov/ncphi/disss/nndss/phs/infdis2008.htm..Accessed.Apr.22,.2008.

115...World.Organization.for.Animal.Health..Diseases.notifiable.to.the.OIE..Available.at:.www.oie.int/eng/maladies/en_clas-sification2007.htm?e1d7..Accessed.Apr.22,.2008.

116...USDA,. Animal. and. Plant. Health. Inspection. Service.. Na-tional.Animal.Health.Reporting.System—reportable.diseas-es.. Available. at:. www.aphis.usda.gov/vs/ceah/ncahs/nahrs/NAHRS_disease_list.htm..Accessed.Apr.22,.2008.

Continued on next page.


Nationally Mostcommonspecies notifiable Severeorprolonged Meansof associatedwith forhuman(H) infectionusually Deaths transmission transmission oranimal associatedwith inhumansDisease Agent tohumans tohumans111–113 (A)cases immunosuppression reported

Acariasis Sarcoptes scabiei, Contact Dogs,cats,horses,goats, No No No(mange) Notoedres cati,and sheep,swine,birds otherspeciesofmites

Anthrax Bacillus anthracis Contact,aerosol, Cattle,sheep,goats,horses H,A No Yes vector

Avianinfluenza Highlypathogenicavian Contact,aerosol Poultry,petbirds H,A No Yes influenzaviruses

Babesiosis Babesia microti Vector Cattle,rodents A Yes Yes andotherspecies

Baylisascariasis Baylisascaris procyonis Contact Raccoons No No Yes Bordetella Bordetella bronchiseptica Aerosol Dogs,swine,rabbits, No Yes No bronchiseptica guineapigsinfection

Brucellosis Brucella melitensis, Contact, Goats,cattle,swine,dogs, H,A No Yes Brucella abortus, aerosol horses Brucella suis, Brucella canis

Campylobacteriosis Campylobacter Contact Cattle,sheep,goats,swine, No No Rare jejuni, Campylobacter dogs,cats,birds,mink, fetus, Campylobacter ferrets,hamsters coli

Capnocytophaga Capnocytophaga Contact Dogs,cats No Yes Yes canimorsus canimorsus,infection Capnocytophaga cynodegmi

Catscratchdisease Bartonella henselae Contact Cats No Yes Rare

Chlamydiosis Chlamydophila abortus, Aerosol,contact Sheep,goats,llamas,cats, No No Yes(mammalian) Chlamydophila felis cattle

Contagious Parapoxvirus Contact Sheep,goats No No Nopustulardermatitis(orforcontagiousecthyma)

Cryptococcosis Cryptococcus neoformans Aerosol Pigeons,otherbirds No Yes Yes

Cryptosporidiosis Cryptosporidium parvum Contact Cattle(typicallycalves) H Yes Yes

Dermatophilosis Dermatophilus congolensis Contact,vector Goats,sheep,cattle,horses No No No

Dermatophytosis Microsporum spp, Contact Cats,dogs,cattle,goats, No Yes No(ringworm) Trichophyton spp, sheep,horses,lagomorphs, Epidermophyton spp rodents

Dipylidium infection Dipylidium caninum Vector Dogs,cats No No No(tapeworm)

Escherichia coli Escherichia coli Contact Cattle,goats,sheep,deer No No YesO157:H7infection O157:H7

Echinococcosis Echinococcus granulosus, Contact Dogs,cats,wildcanids A No Yes Echinococcus multilocularis

Ehrlichiosisor EhrlichiaandAnaplasma spp Vector Deer,rodents,horses,dogs H Yes Yesanaplasmosis

Equine Togaviridae(eastern, Vector Birds,horses H,A No Yesencephalomyelitis western,andVenezuelan equineencephalomyelitis viruses)

Erysipeloid Erysipelothrix rhusiopathiae Contact Swine,poultry,fish,crustaceans, No No Yes mollusks

Giardiasis Giardia intestinalis Contact Thoughttobehighly H Yes No (Giardia lamblia) species-specificandrarely transmittedfromanimals tohumans

Hantaviraldiseases Hantaviruses Aerosol Rodents H No Yes

HerpesBvirus Cercopithecine Contact Macaquemonkeys No No Yesinfection herpesvirus1

InfluenzaA InfluenzaAvirus Contact,aerosol Poultry,swine H,A No Yes

Larvalmigrans: Ancylostoma spp Contact Dogs,cats No No Rarecutaneous(hookworm)

Appendix 1

ZoonoticdiseasesofimportanceintheUnitedStates,2008.


Nationally Mostcommonspecies notifiable Severeorprolonged Meansof associatedwith forhuman(H) infectionusually Deaths transmission transmission oranimal associatedwith inhumansDisease Agent tohumans tohumans111–113 (A)cases immunosuppression reported

Larvalmigrans: Toxocara canis, Contact Dogs,cats No No Rarevisceral,ocular, Toxocara catineurologic(roundworm)

Leishmaniasis Leishmaniaspp Vector Dogs,wildcanids A No YesLeptospirosis Leptospira spp Contact,aerosol Rodents,swine,cattle, A No Yes sheep,goats,horses,dogs

Listeriosis Listeria monocytogenes Contact Cattle,sheep,goats,swine, H Yes Yes birds,dogs,cats

Lymedisease Borrelia burgdorferi Vector Smallrodents,wildmammals H No No Lymphocytic Arenavirus(lymphocytic Contact,aerosol Mice,hamsters,guineapigs No Yes Yeschoriomeningitis choriomeningitisvirus) Monkeypox Orthopoxvirus Contact,aerosol Nonhumanprimates,rodents A No Yes Mycobacterial Mycobacterium Aerosol, Poultry,birds, No Yes Yesinfection avium complex, contact aquariumfish,(nontuberculous) Mycobacterium reptiles marinum

Pasteurellosis Pasteurella multocidaand Contact Dogs,cats,rabbits,rodents No Yes No otherspecies Plague Yersinia pestis Vector,contact, Rodents,cats,lagomorphs H,A No Yes aerosol Psittacosisor Chlamydophila psittaci Aerosol,contact Petbirds,poultry H Yes Yeschlamydiosis

Qfever Coxiella burnetii Contact,aerosol, Goats,sheep,cattle, H,A No Yes vector rodents,lagomorphs, dogs,cats Rabies Lyssavirus Contact Cats,dogs,cattleandother H,A No Yes domesticanimals,wild carnivores,raccoons, bats,skunks,foxes

Ratbitefever Streptobacillus moniliformis, Contact Rodents No Yes Yes Spirillum minus

Rhodococcus equi Rhodococcus equi Aerosol,contact Horses No Yes Yesinfection

RockyMountain Rickettsia rickettsii Vector Dogs,rabbits,rodents H No Yesspottedfever Salmonellosis Salmonellaspp Contact Reptiles,amphibians,poultry, H Yes Yes horses,swine,cattle,pocket pets,manyspeciesofmammals andbirds

Sporotrichosis Sporothirix schenckii Contact Cats,dogs,horses No Yes Rare Staphylococcosis Staphylococcus species Contact Dogs,cats,horses H(VRSA,VISA) Yes Yes(some forms)

Streptococcosis Streptococcusspecies Contact,aerosol Swine,fish,othermammals H(someforms) No Yes(some forms)

Toxoplasmosis Toxoplasma gondii Contact Cats No Yes Yes Trichuriasis Trichuris suis, Trichuris Contact Dogs,swine No No Rare(whipworminfection) trichiura, Trichuris vulpis Tuberculosis,bovine Mycobacterium bovis Aerosol,contact Cattle,swine,sheep,goats H,A No Yes Tularemia Francisella tularensis Vector,contact, Lagomorphs,pocketpets, H,A No Yes aerosol wildaquaticrodents,sheep, cats,horses,dogs

Vesicularstomatitis Vesicularstomatitis Vector,contact, Horses,cattle,swine,sheep, A No No virus aerosol goats

WestNilefever WestNilevirus Vector Wildbirds H,A No Yes

Yersiniosis Yersinia enterocolitica Contact Swine,manyspeciesof No No No mammalsandbirds

DataregardingnationallyreportablediseaseswereobtainedfromtheCDC’snationallynotifiableinfectiousdiseaseslist,theWorldOrganizationforAnimalHealth(OIE)notifiableanimaldiseaseslist,andtheUSDAAnimalandPlantHealthInspectionServicereportablediseaseslist.114–116Casesmayalsobenotifiableatthestatelevel;stateveterinariansorstatepublichealthveterinariansshouldbeconsultedforcurrentlistingsofreportablediseasesinspecificareas.

Appendix 1ZoonoticdiseasesofimportanceintheUnitedStates,2008(continued).



Appendix 2

Selecteddisinfectantsusedinveterinarypractice.


Appendix 3

ModelInfectionControlPlanforVeterinaryPractices,2008

NationalAssociationofStatePublicHealthVeterinarians(NASPHV)VeterinaryInfectionControlCommittee(VICC)

This plan should be adapted to your practice in keeping with local, state and federal regulations. A modifiable electronic version is available on the NASPHV Web site (www.nasphv.org). Please refer to the full Compendium of Veterinary Standard Precautions for complete information and guidance (also available at www.nasphv.org).

Clinic:DateofPlanAdoption:DateofNextReview:InfectionControlOfficer:

Thisplanwillbefollowedaspartofourpractice’sroutineprocedures.Theplanwillbereviewedatleastannuallyandaspartofnewemployeetraining.

PERSONALPROTECTIVEACTIONSANDEQUIPMENTHandhygiene:Washhandsbeforeandaftereachpatientencounterandaftercontactwithfeces,blood,bodyfluids,secretions,excretions,exudates,orarticlescontaminatedbythesesubstances.Washhandsbeforeeating,drinking,orsmoking;afterusingthetoilet;aftercleaninganimalcagesoranimal-careareas;andwheneverhandsarevisiblysoiled.Alcohol-basedrubsmaybeusedifhandsarenotvisiblysoiled,buthandwashingwithsoapandrunningwaterispreferred.Keepfingernailsshort.Donotwearartificialnailsorhandjewelrywhenhandlinganimals.Keephand-washingsuppliesstockedatalltimes.Staffresponsible:

Correcthand-washingprocedure:-Wethandswithrunningwater-Placesoapinpalms-Rubhandstogethertomakealather-Scrubhandsvigorouslyfor20seconds-Rinsesoapoffhands-Dryhandswithdisposabletowel-Turnofffaucetusingthedisposabletowelasabarrier

Useofglovesandsleeves:Glovesarenotnecessarywhenexaminingorhandlingnormal,healthyanimals.

Wearglovesorsleeveswhentouchingfeces,blood,bodyfluids,secretions,excretions,exudates,andnon-intactskin.Wearglovesfordentistry,resuscitations,necropsies,andobstetricalprocedures;whencleaningcages,litterboxes,andcontaminatedenvironmentalsurfacesandequipment;whenhandlingdirtylaundry;whenhandlingdiagnosticspecimens(eg,urine,feces,aspirates,orswabs);andwhenhandlingananimalwithasuspectedinfectiousdisease.Changeglovesbetweenexaminationofindividualanimalsoranimalgroups(eg,alitterofpuppies)andbetweendirtyandcleanproceduresperformedonthesamepatient.Glovesshouldberemovedpromptlyanddisposedofafteruse.Disposableglovesshouldnotbewashedandreused.Handsshouldbewashedimmediatelyaftergloveremoval.

Facialprotection:Wearfacialprotectionwheneverexposuretosplashesorspraysislikelytooccur.Facialprotectionincludesasurgicalmaskwornwithgogglesorafaceshield.Wearfacialprotectionforthefollowingprocedures:lancingabscesses,flushingwounds,dentistry,nebulization,suctioning,lavage,obstetricalprocedures,andnecropsies.

Protectiveouterwear:Wearaprotectiveoutergarmentsuchasalabcoat,smock,non-sterilegown,orcoverallswhenattendinganimalsandwhenconductingcleaningchores.Theseshouldbechangedwheneversoiled,afterhandlingananimalwithaknownorsuspectedinfectiousdisease,afterworkinginanisolationroom,andafterperforminganecropsyorotherhigh-riskprocedure.Shoesorbootsshouldhavethicksolesandclosedtoesandbeimpermeabletowaterandeasilycleaned.Disposableshoecoversshouldbewornwhenheavyquantitiesofinfectiousmaterialsarepresentorexpected.Impermeableoutwearshouldbewornduringobstetricproceduresandnecropsiesandwheneversubstantialsplashesorlargequantitiesofbodyfluidsmaybeencountered.Keepcleanoutergarmentsavailableatalltimes.Staffresponsible:

Biteandotheranimal-relatedinjuryprevention:Takeprecautionstopreventbitesandotherinjuries.Identifyaggressiveanimalsandalertclinicstaff.Usephysicalrestraints,muzzles,bite-resistantgloves,andsedationoranesthesiainaccordancewithpracticepolicies.Plananescaperoutewhenhandlinglargeanimals.Donotrelyonownersoruntrainedstaffforanimalrestraint.• Ifthereisconcernforpersonalsafety,notify:• Wheninjuriesoccur,washwoundswithsoapandwater,thenimmediatelyreportincidentto:(InfectionControlOfficer)• Ifmedicalattentionisneededcontact:(health-careprovider)• Biteincidentswillbereportedto:(publichealthagency)asrequiredbylaw.Telephonenumber:

PROTECTIVEACTIONSDURINGVETERINARYPROCEDURESIntake:Avoidbringingaggressiveorpotentiallyinfectiousanimalsinthroughthereceptionarea.Iftheymustcomethroughthemainentrance,ifpossible,carrytheanimalorplaceitonagurneysothatitcanbetakendirectlyintoadesignatedexaminationroom.

Examinationofanimals:Wearappropriateprotectiveouterwear,andwashhandsbeforeandafterexaminationofindividualanimalsoranimalgroups(eg,alitterofpuppies).Potentiallyinfectiousanimalswillbeexaminedinadesignatedexaminationroomandremainthereuntildiagnosticproceduresandtreatmentshavebeenperformed.

Injections,venipuncture,andaspirationprocedures:Weargloveswhileperformingvenipunctureonanimalssuspectedofhavinganinfectiousdiseaseandwhenperformingsofttissueaspirations.

Needlestickinjuryprevention:Donotrecapneedlesexceptinrareinstanceswhenrequiredaspartofamedicalprocedureorprotocol.Donotremoveanuncappedneedlefromthesyringebyhandorplaceaneedlecapinthemouth.Disposeofallsharpsindesignatedcontainers.Afterinjectionoflive-organismvaccinesoraspirationofbodyfluids,disposeofusedsyringeswithattachedneedlesinasharpscontainer.Otherwise,removetheneedlebyuseofforcepsortheneedleremovaldeviceonthesharpscontainer,andthrowthesyringeawayinthetrash.Donottransfersharpsfromonecontainertoanother.Replacesharpscontainersbeforetheyarecompletelyfull.Staffresponsible:

Dentalprocedures:Wearprotectiveouterwear,gloves,andfacialprotectionwhenperformingdentalproceduresorwheninrangeofsplashesorsprays(suchaswhenmonitoringanesthesia).

Resuscitation:Wearglovesandfacialprotection.

Obstetrics:Wearglovesorshoulder-lengthsleeves,facialprotection,andimpermeableouterwear.



Appendix 3 (continued)

Necropsy:Wearcut-resistantgloves,facialprotection,andimpermeableouterwear.Onlynecessarypersonnelareallowedinthevicinityoftheprocedure.Weararespiratorwhenusingabandsaworotherpowerequipment.Ifananimalissuspectedofhavinganotifiableinfectiousoraforeignanimaldisease,consultwiththeStateVeterinarianbeforeproceedingwithanecropsy.ContactinformationforStateVeterinarian’soffice:

Diagnostic-specimenhandling:Wearprotectiveouterwearandgloves.Discardglovesandwashhandsbeforetouchingcleanitems(eg,medicalrecords,telephone).Eatinganddrinkingarenotallowedinthelaboratory.

ENVIRONMENTALINFECTIONCONTROLIsolationofinfectiousanimals:Animalswithacontagiousorzoonoticdiseasewillbehousedinisolationassoonaspossible.Clearlymarktheroomorcagetoindicatethepatient’sstatus,anddescribeadditionalprecautions.Keeponlytheequipmentneededforthecareandtreatmentofthepatientintheisolationroom,includingdedicatedcleaningsupplies.Disassembleandthoroughlycleananddisinfectanyequipmentthatmustbetakenoutoftheroom.Discardglovesafteruse.Leaveotherpersonalprotectiveequipment(eg,gown,mask)intheisolationroomforreuse.Cleananddisinfectordiscardprotectiveequipmentbetweenpatientsandwhenevercontaminatedbybodyfluids.Placepotentiallycontaminatedmaterialsinabagbeforeremovalfromtheisolationroom.Useadisinfectantfootbathbeforeenteringandleavingtheroom.Limitaccesstotheisolationroom.Keepasign-inlogofallpeople(includingownersorothernon-employees)havingcontactwithananimalinisolation.Monitorairpressuredailywhiletheroomisinuse.Staffresponsible:Cleaninganddisinfectionofequipmentandenvironmentalsurfaces:First,cleansurfacesandequipmenttoremoveorganicmatter,andthenuseadisinfectantaccordingtomanufacturer’sinstructions.Minimizedustandaerosolswhencleaningbyfirstmistingtheareawithwaterordisinfectant.Cleananddisinfectanimalcages,toys,andfoodandwaterbowlsbetweenusesandwhenevervisiblysoiled.Cleanlitterboxesonceaday.Weargloveswhencleaning,andwashhandsafterwards.Thereisawrittenchecklistforeachareaofthefacility(eg,waitingroom, examinationrooms,treatmentarea,andkennels)thatspecifiesthefrequencyofcleaning,disinfectionprocedures,productstobeused,andstaffresponsible.

Handlinglaundry:Weargloveswhenhandlingsoiledlaundry.Washanimalbeddingandotherlaundrywithstandardlaundrydetergentandmachinedry.Useseparatestorageandtransportbinsforcleananddirtylaundry.

Decontaminationandspillresponse:Immediatelysprayaspillorsplashofblood,feces,orotherpotentiallyinfectioussubstancewithdisinfectantandcontainitwithabsorbentmaterial(eg,papertowels,sawdust,catlitter).Putongloves,mask,andprotectiveclothing(includingshoecoversifthespillislargeandmaybesteppedin)beforebeginningthecleanup.Pickupthematerial,sealitinaleak-proofplasticbag,andcleananddisinfectthearea.Keepclients,patients,andemployeesawayfromthespillareauntildisinfectioniscompleted.

Veterinarymedicalwaste:Insert here your local and state ordinances regulating disposal of animal waste, pathology waste, animal carcasses, bedding, sharps, and biologics. Refer to the US Environmental Protection Agency Web site for guidance: www.epa.gov/epaoswer/other/medical.

Rodentandvectorcontrol:Sealentryportals,eliminateclutterandsourcesofstandingwater,keepanimalfoodinclosedmetalorthickplasticcoveredcontainers,anddisposeoffoodwasteproperlytokeepthefacilityfreeofwildrodents,mosquitoes,andotherarthropods.

Otherenvironmentalcontrols:Therearedesignatedareasforeating,drinking,smoking,applicationofmake-up,andsimilaractivities.Theseactivitiesshouldneveroccurinanimal-careareasorinthelaboratoryarea.Donotkeepfoodordrinkforhumanconsumptioninthesamerefrigeratorasfoodforanimals,biologics,orlaboratoryspecimens.Dishesforhumanuseshouldbecleanedandstoredawayfromanimal-careandanimalfood–preparationareas.EMPLOYEEHEALTHInfectioncontrolandemployeehealthmanagement:Thefollowingpersonnelareresponsiblefordevelopmentandmaintenanceofthepractice’sinfectioncontrolpolicies,recordkeeping,andmanagementofworkplaceexposureandinjuryincidents.Staffresponsible:

Recordkeeping:Currentemergencycontactinformationwillbemaintainedforeachemployee.Recordswillbemaintainedonvaccinations,rabiesvirusantibodytiters,andexposureandinjuryincidents.Reportandrecordchangesinhealthstatus(eg,pregnancy)thatmayaffectworkduties.

Preexposurerabiesvaccination:Allstaffwithanimalcontactmustbevaccinatedagainstrabies,followedbyperiodictiterchecksandrabiesvaccineboosters,inaccordancewiththerecommendationsoftheAdvisoryCommitteeonImmunizationPractices(CDC,2008).

Tetanusvaccination:Tetanusvaccinationmustbeuptodate.Reportandrecordpuncturewoundsandotherincidents.Consultahealth-careproviderregardingtheneedforatetanusbooster.

Influenzavaccination:Unlesscontraindicated,veterinarypersonnelareencouragedtoreceivethecurrentinfluenzavirusvaccine.RefertotheCentersforDiseaseControlandPreventionWebsiteforguidance(www.cdc.gov).

Stafftrainingandeducation:Infectioncontroltrainingandeducationwillbedocumentedintheemployeehealthrecord.

Documentingandreportingexposureincidents:Reportincidentsthatresultininjuryorpotentialexposuretoaninfectiousagentto:Thefollowinginformationwillbecollectedforeachexposureincident:date,time,location,person(s)injuredorexposed,otherpersonspresent,descriptionoftheincident,whetherahealth-careproviderwasconsulted,thestatusofanyanimalsinvolved(eg,vaccinationhistory,clinicalcondition,anddiagnosticinformation),andplansforfollow-up.

Pregnantandimmunocompromisedpersonnel:Pregnantandimmunocompromisedemployeesareatincreasedriskfromzoonoticdiseases.Inform:ifyouareconcernedaboutyourworkresponsibilities,sothataccommodationsmaybemade.Consultationbetweenthesupervisingveterinarianandahealth-careprovidermaybeneeded.

ThefollowinginformationisattachedtotheInfectionControlPlan:• Emergencyservicestelephonenumbers—fire,police,sheriff,animalcontrol,poisoncontrol,etc• Reportableornotifiableveterinarydiseasesandwheretoreport• StateDepartmentofAgricultureorBoardofAnimalHealthcontactinformationandregulations• Stateandlocalpublichealthcontactsforconsultationonzoonoticdiseases• PublicHealthLaboratoryservicesandcontactinformation• EnvironmentalProtectionAgency(EPA)-registereddisinfectants• OccupationalSafetyandHealthAdministration(OSHA)regulations• Animalwaste–disposalandbiohazardregulations• Rabiesregulations• Animalcontrolandexoticanimalregulationsandcontacts• Otherusefulresources

Guidelines for animal-assistedinterventions in health care facilitiesWriting Panel of the Working Group: Sandra L. Lefebvre, DVM, PhD,a Gail C. Golab, PhD, DVM,b E’Lise Christensen, DVM,c

Louisa Castrodale, DVM, MPH,d Kathy Aureden, MS, CIC,e Anne Bialachowski, RN, MS, CIC,f Nigel Gumley, DVM,g JudyRobinson,h Andrew Peregrine, DVM, PhD,a Marilyn Benoit, RN,i Mary Lou Card, RN, CIC,j Liz Van Horne, RN, CIC,k andJ. Scott Weese, DVM, DVSca

Schaumburg and Elgin, Illinois; New York, New York; Anchorage, Alaska; Guelph, Burlington, Ottawa, Hamilton,London, and Toronto, Ontario, Canada

Many hospitals and long-term care facilities in North America currently permit animals to visit with their patients; however, thedevelopment of relevant infection control and prevention policies has lagged, due in large part to the lack of scientific evidenceregarding risks of patient infection associated with animal interaction. This report provides standard guidelines for animal-assistedinterventions in health care facilities, taking into account the available evidence. (Am J Infect Control 2008;36:78-85.)

The popularity of animal-assisted interventions(AAIs) in human health care has grown to the pointwhere many hospitals and long-term care facilities inNorth America currently permit animals to visit with

From the Ontario Veterinary College, University of Guelph, Guelph,Ontario, Canada;a American Veterinary Medical Association, Schaum-burg, IL;b NYC Veterinary Specialists, New York, NY;c Alaska Depart-ment of Health and Social Services, Section of Epidemiology,Anchorage, AK;d Sherman Hospital, Elgin, IL;e Joseph Brant Com-munity Health Centre, Burlington, Ontario, Canada;f Canadian Veteri-nary Medical Association, Ottawa, Ontario, Canada;g St JohnAmbulance Therapy Dogs, Hamilton, Ontario, Canada;h Ottawa Ther-apy Dogs, Ottawa, Ontario, Canada;i St Joseph’s Health Care, London,Ontario, Canada;j and Public Health Division, Ontario Ministry ofHealth and Long-Term Care, Toronto, Ontario, Canada.k

Address correspondence to J. Scott Weese, DVM, DVSc, Departmentof Clinical Studies, University of Guelph, Guelph, Ontario, CanadaN1G 2W1. E-mail: [email protected].

Other Working Group members include Erica Bontovics, MD, CIC, andSharon Calvin, DVM, MSc, Ontario Ministry of Health and Long-TermCare; Nora Boyd, RN, CIC, Bluewater Health, Sarnia, Ontario; ReneeFreeman, RN, CIC, and Michael Hawkes, MDCM, The Hospital forSick Children, Toronto, Ontario; Cindy Plante-Jenkins, MLT, CIC, Tril-lium Health Centre, Mississauga, Ontario; Joanne Laalo, RN, CIC, Com-munity and Hospital Infection Control Association of Canada; RobertFranklin, DVM, Delta Society; Carol Jones, Jan Vallentin, and Don Lap-ierre, St John Ambulance Therapy Dogs; Judy Sauve and Nancy Trus,Therapeutic Paws of Canada; David Waltner-Toews, DVM, PhD, Univer-sity of Guelph, Ontario; and Richard Reid-Smith, DVM, DVSc and RitaFinley, MSc, Public Health Agency of Canada.

The Working Group meeting was sponsored by the Public HealthAgency of Canada and the Centre for Public Health and Zoonoses, Uni-versity of Guelph.

0196-6553/$34.00

Copyright ª 2008 by the Association for Professionals in InfectionControl and Epidemiology, Inc.

doi:10.1016/j.ajic.2007.09.005

78

patients and residents. But while the use of AAIs andthe evidence supporting their many benefits forpatients/residents has grown,1-5 the development ofapplicable infection control policies has lagged. Conse-quently, current practices for animal health screeningand infection prevention and control are highly varia-ble both within and between health care facilities(HCFs). Patients’ and others’ pets are not held to thesame standards as animals belonging to formal AAIprograms, even though any of these animals caninteract with patients and health care staff. Althoughgeneral guidelines for animal visitors have been pub-lished by several expert groups,6-9 a collaborative doc-ument that captures the interests of most stakeholderswhile providing specific recommendations to mini-mize both injuries and the transmission of infectiousorganisms to and from animals is needed.

To address this demand, a Working Group of stake-holders in AAI assembled in Toronto, Ontario on Janu-ary 9, 2007, with the aim of finalizing a draft set ofguidelines that had been prepared by the project leaders(JSW and SL) and circulated for preliminary commentsbefore the meeting. The participants included 29 indi-viduals with expertise in AAI, infection control, publichealth, and veterinary medicine from Canada and theUnited States. Led by a professional facilitator, theWorking Group reviewed all identified evidence regard-ing the risks of AAI,10-25 then systematically debatedeach point in the draft document for its validity, consid-ering both the evidence and expert opinion. Issuesrequiring further discussion were delegated to expertsubcommittees for resolution. Subcommittee recom-mendations were subsequently circulated to all Work-ing Group members for their approval.

mailto:[email protected]

Writing Panel of the Working Group March 2008 79

The final recommendations were annotated accord-ing to 2 different classifications. The quality of evidencesupporting each recommendation was ranked follow-ing the system used by the Centers for Disease Controland Prevention in other infection control guidelines(Table 1). In addition, the degree of consensus achievedby the Working Group, as defined in Table 2, was noted.

This report represents the final product of that meet-ing. Its purpose is to provide explicit and, wheneverpossible, evidence-based guidelines to mitigate risksassociated with AAI. The intended audience is humanhealth care workers (including those that provideAAIs themselves), although the responsibilities for car-rying out many of the recommendations will rest withanimal handlers, as well as external organizations thatprovide AAI services. Explicit guidelines for veterinar-ians, including rationales behind the recommenda-tions relevant to animal selection and screening, willbe published separately. Special circumstances relatedto resident animals (that also are used in AAI pro-grams), service animals, laboratory animals, or animals

Table 1. Rating categories for recommendations7

Category Description

IA Strongly recommended

for implementation and strongly

supported by well-designed

experimental, clinical,

or epidemiologic studies

IB Strongly recommended

for implementation and supported

by certain experimental,

clinical, or epidemiologic

studies and a strong

theoretic rationale

IC Required by provincial/territorial,

state, or federal

regulation, or representing

an established association standard

II Suggested for implementation

and supported by limited

clinical or epidemiologic

studies, or by a theoretic rationale

Unresolved issue No recommendation

is offered. No scientific

consensus or insufficient

evidence exists regarding efficacy.

Table 2. Level of consensus agreement among membersof the Working Group

Rating Explanation

Consensus More than 80% agreement

among Working Group members

Nonconsensus Less than 80% agreement

among Working Group members

that are brought into human HCFs for veterinary diag-nostics and treatment, are not addressed here for thesake of brevity. The guidelines herein are based onavailable evidence and may require updating in the fu-ture as other issues come to light.

Rather than recommending a rigorous screeningprotocol to identify animal carriage of specific patho-gens, the guidelines place a major emphasis on all indi-viduals (patients and staff) practicing hand hygienebefore and after handling animals, as well as on otherinfection prevention and control strategies to minimizethe spread of pathogens from or to animals. The needfor facilities to delegate a single individual—an animalvisit liaison—to be aware of all animals entering thepremises is also identified. Similarly, a method to facil-itate contact tracing in the event of potentially zoonoticpatient infections (or handler/animal contact with con-tagious patients) is suggested.

Because animals may interact with various popula-tions that may be at risk of infection or injury, certain re-strictions on animal species, age, origin, behavior, diet,and health status are recommended for animals in for-mal AAI programs, whether these programs are run bythe HCF itself or by an external agency. For visits by pa-tients’ pets, the emphasis is placed on animals meetingcertain basic health and diet requirements, and also onlimiting human contact during the visit to the relevantpatient only (ie, no other patients or staff). Animal visi-tors falling outside of these 2 categories (eg, thosebrought in by well-meaning community memberswith no training in AAI) should be denied entry.

GUIDELINES FOR ANIMALS VISITING HEALTHCARE FACILITIES

I. Hand hygiene practices1. Require that all patients, visitors and health care

workers practice hand hygiene both before andafter each animal contact.6,26 (IB, Consensus)

2. Require that animal handlers carry an alcohol-based hand rub product with them, and thatthey offer the product to anyone who wishes totouch the animal. Ideally, this product should besupplied by the HCF. (II, Consensus)

3. Require that animal handlers practice personalhand hygiene in accordance with the HCF’s policyfor volunteers and employees.26 (II, Consensus)

II. Facility management of programs for animalvisitation1. Recommend that the HCF develop an animal vis-

itation program or policies for patient-owned an-imals and for AAIs. (II, Consensus)

2. Recommend that the HCF designate an animalvisit liaison (AVL) to provide support and facilita-tion to animal handlers visiting the facility. The

80 Vol. 36 No. 2 Writing Panel of the Working Group

AVL’s duties should include keeping appraised ofall animals entering the facility. (II, Consensus)

III. Determining suitability of animals by species, age,and origin

1. Patients’ animalsa. Restrict suitable animal species to domestic

companion animals that are household pets.(IB, Consensus)

b. No age restriction is recommended, providedthat the animal is under the control of a handlerother than the patient at all times. (II,Consensus)

c. Do not allow patient-owned animals to visitother patients, visitors, staff, or animals. (II,Consensus)

2. AAI animalsa. Restrict suitable animal species to domestic

companion animals that are household pets.(IB, Consensus) Exclude those species identi-fied as being of higher risk of causing humaninfection or injury, including:d Reptiles and amphibians (eg, lizards, turtles,

frogs, salamanders)25,27-30 (IB, Consensus)d Nonhuman primates31,32 (IB, Consensus)d Hamsters, gerbils, mice, and rats33,34 (IB,

Consensus)d Hedgehogs, prairie dogs, or any other re-

cently domesticated animal species35-37 (IB,Consensus)

d Other animals that have not been litter-trained or for which no other measurescan be taken to prevent exposure of pa-tients/residents to animal excrement38 (II,Consensus)

b. Deny the entry of any animal directly from ananimal shelter, pound, or similar facility.39-44

(IB, Consensus)c. Require that an animal be in a permanent

home for at least 6 months to be consideredfor visiting patients.45 (II, Consensus)

d. Require that all AAI animals be adults, withcats being at least 1 year of age and dogs atleast 1 year but ideally 2 years of age (the ageof social maturity).46 (IB, Consensus)

e. Admit an animal only if it is a member of a for-mal AAI program (whether run by the HCF oran external entity) and is present exclusivelyfor the purposes of AAI. (II, Consensus)

IV. Determining suitability of animals for AAI programsby temperament

1. Verify that the AAI program, whether run by theHCF or an external entity, requires a tempera-ment evaluation for all participating animals.

2. Require that every animal pass a temperamentevaluation specifically designed to evaluate the

behavior of AAI animals under conditions thatthey might encounter when in HCFs. Such an eval-uation process should assess, among other factors:a. Reactions toward strangersb. Reactions to loud and/or novel stimulic. Reactions to angry voices and potentially

threatening gesturesd. Reactions to being crowdede. Reactions to being patted in a vigorous or

clumsy mannerf. Reactions to a restraining hugg. Reactions to other animalsh. Ability to obey handler’s commands.47 (IC,

Consensus)3. Require all evaluators to successfully complete a

course or certification process in evaluatingtemperament and to have experience in assess-ing animal behavior and level of training. (IC,Consensus)a. Require all evaluators to have experience with

animal visiting programs or, at the very least,appreciate the types of challenges that animalsmay encounter in the health care environment(eg, startling noises, crowding, rough han-dling).47 (IC, Consensus)

b. If several animals need to be evaluated for be-haviors other than reactions to other animals,require that the temperament evaluator as-sess each animal separately, rather than as-sessing several animals simultaneously. (II,Consensus)

4. Require that animal-handler teams be observedby an AAI program representative at least oncein a health care setting before being granted finalapproval to visit. (II, Consensus)

5. Recommend that each animal be reevaluated atleast every 3 years (Unresolved issue, Consensus).No recommendation is made regarding whetherthe reevaluation should consist of a formal temper-ament evaluation in a controlled setting or a spotcheck by AAI program representatives or AVLs dur-ing a routine visit; however, if the latter option ischosen, then annual reevaluation is suggested.

6. Require that a handler suspend visits and havehis or her animal formally reevaluated wheneverhe or she notices or is apprised (either directly orthrough the AVL) that the animal has demon-strated any of the following:a. A negative behavioral change (as described in

IV.2.a to h) since the time it was last tempera-ment-tested (II, Consensus)

b. Aggressive behavior outside the health caresetting (II, Consensus)

c. Fearful behavior during visitations (II,Consensus)


d. Loss of sight or hearing and, consequently, anovert inclination to startle and react in an ad-verse manner (II, Consensus)

7. Require that any animal be formally reevaluatedbefore returning to AAIs after an absence of 6months or longer. (II, Consensus)

8. Requiring that cats be declawed to preventscratches is not recommended. (II, Consensus)

V. Health screening of animals1. Basic requirements for all animals

a. Require that dogs and cats be vaccinatedagainst rabies as dictated by local laws. (IC,Consensus)(1) Exemption of rabies vaccine-sensitive ani-

mals may be granted on a case-by-case ba-sis and only in areas where the risk ofexposure to rabies is considered very low.(II, Consensus)

(2) Serologic testing for rabies antibody con-centration should not be used as a substi-tute for vaccination. (II, Consensus)

b. For the protection of both the animal and peo-ple, prevent the animal from entering the HCFstarting from the onset of and until at least1 week beyond the resolution of:(1) Episodes of vomiting or diarrhea(2) Urinary or fecal incontinence(3) Episodes of sneezing or coughing of un-

known or suspected infectious origin(4) Treatment with nontopical antimicrobials

or with any immunosuppressive doses ofmedications

(5) Open wounds(6) Ear infections(7) Skin infections or ‘‘hot spots’’ (ie, acute

moist dermatitis)(8) Orthopedic or other conditions that, in the

opinion of the animal’s veterinarian, couldresult in pain or distress to the animal dur-ing handling and/or when maneuveringwithin the facility

(9) Demonstrating signs of heat (estrus). (II,Consensus)

2. Scheduled health screening of AAI animalsa. Require that every animal receive a health

evaluation by a licensed veterinarian at leastonce (optimally, twice) per year. (II,Consensus)(1) Defer to the animal’s veterinarian regard-

ing an appropriate flea, tick, and entericparasite control program, which shouldbe designed to take into account the risksof the animal acquiring these parasites spe-cific to its geographic location and livingconditions. (IB, Consensus)

(2) Temporarily withdraw any animal withfleas, ticks, or mange (mite infestation) andtreat as directed by the animal’s veterinarianuntil the infestation has cleared, as deter-mined by the veterinarian. (IB, Consensus)

b. Routine screening for specific, potentiallyzoonotic microorganisms, including group Astreptococci, Clostridium difficile, vancomycin-resistant enterococci, and methicillin-resistantStaphylococcus aureus (MRSA), is not recom-mended.19,21,22 (IB, Consensus)(1) Special testing may be indicated in situa-

tions where the animal has physicallyinteracted with a known human carrier, ei-ther in the hospital or in the community, orwhen epidemiologic evidence suggests thatthe animal might be involved in transmis-sion. Testing should be performed by theanimal’s veterinarian, in conjunction withappropriate infection control and veteri-nary infectious disease/internal medicinepersonnel, if required. (II, Consensus)

(2) Special testing may be indicated if the AAIanimal is epidemiologically linked to an out-break of infectious disease known to havezoonotic transmission potential. Suspen-sion of visitation pending results is recom-mended in these situations. (II, Consensus)

VI. Dietary guidelines for all animals1. Exclude any animal that has been fed any raw or

dehydrated (but otherwise raw) foods, chews, ortreats of animal origin within the past 90days.48-50 (IA, Consensus)

VII. Training and management of animal handlers1. Handlers of patients’ animals

a. Ensure that the animal’s handler has been in-formed of the HCF’s policy for animal visitsand has signed an agreement to comply withthis policy. (II, Consensus)

b. Request that documentation of current rabiesimmunization be provided to the approvingauthority for patient-owned animal visits. (IC,Consensus)

c. Ensure that the visitor and the animal are es-corted to their destination, as arranged by theAVL. (II, Consensus)

d. Ensure that every unleashed animal is carriedin a clean carrier and not released until reach-ing the patient. (II, Consensus)

e. Ensure that a dog is leashed if not in a carrier andtaken to the patient by the route least likely to ex-pose other patients to the animal. (II, Consensus)

f. Advise the handler of a patient-owned animalthat he or she should expect others (patients,health care workers, or visitors) to notice the


animal and want to interact with it. Instruct thehandler to deny such requests and to avoidsuch interactions. (II, Consensus)

2. Handlers of AAI animals onlya. Require that every handler participate in a for-

mal training program and an evaluation of thattraining, which includes modules on:(1) Zoonoses(2) Infection control practices (including proper

cleanup and disposal of animal excrement)(3) Identifying appropriate contacts in the

event of an accident or injury(4) Visual inspection for ectoparasites(5) Reading an animal’s body language to

identify signs of physical discomfort,stress, fear, or aggression

(6) Patient confidentiality. (II, Consensus)b. Require that each handler comply with the

HCF’s policy for influenza vaccination andany additional human health screening re-quirements in place for volunteers and em-ployees. (II, Consensus)

c. Require that a handler use particular care in di-recting the visit to prevent patients from touch-ing the animal in inappropriate body sites (eg,mouth, nose, perianal region) or handling theanimal in a manner that might increase thelikelihood of frightening or harming the ani-mal or the animal harming the patient acciden-tally. (II, Consensus)

d. Restrict visiting sessions to a maximum of1 hour, to reduce the risk of adverse events as-sociated with animal fatigue. (II, Consensus)(1) Observe the animal for signs of fatigue,

stress, thirst, overheating, or urges to uri-nate or defecate. (II, Consensus)

(2) If taking a short break (or taking the animaloutside to relieve itself) will not ease theanimal’s signs of discomfort, then termi-nate the session for that day. (II, Consensus)

(3) Require that the handler comply withfacility-defined restrictions for patient vis-itation and to be familiar with facility-specific signage regarding restricted areasor rooms. (II, Consensus)

3. Require that all animal handlers:a. Self-screen for symptoms of communicable

disease and refrain from visiting while ill.51

Such symptoms include, but are not limited to:(1) New or worsening coughing or sneezing(2) Nasal discharge(3) Fever (temperature . 388C)(4) Diarrhea and/or vomiting(5) Conjunctivitis(6) Rash. (IC, Consensus)

b. Limit visits to 1 animal per handler. (II,Consensus)

c. Keep control of the animal at all times while onthe premises. (II, Consensus)(1) Keep a dog leashed at all times unless

transported within the facility by a carrier(as may be the case with smaller breeds).(II, Consensus)

(2) Transport an off-leash animal in a cleancarrier between rooms. (II, Consensus)

(3) Refrain from using cell phones or partici-pating in other activities that may divertthe handler’s attention away from the ani-mal. (II, Consensus)

d. Approach patients from the side that is freeof any invasive devices, such as intrave-nous catheters, and prevent the animalfrom contacting any insertion sites. (II,Consensus)

e. Prevent the animal from licking or bumpingagainst medical devices. (II, Consensus)

f. Before entering an elevator with an animal,ask the other passengers for permission, anddo not enter if any passenger asks that the an-imal not enter or if a passenger appears to beapprehensive around the animal. (II,Consensus)(1) For a patient’s animal, prevent non–family

members from handling the animal. (II,Consensus)

(2) For an AAI animal, require that everyonewho wishes to touch the animal practicehand hygiene before and after contact. (II,Consensus)

g. Do not visit with a patients while he or she iseating or drinking, and do not permit a patientto eat or drink while interacting with the ani-mal. (II, Consensus)

h. Wear gloves to clean up any animal excreta(urine, vomitus, or feces), and dispose of thematerial according to the HCF’s biowaste man-agement policy. Report the incident to healthcare staff so that the area can be properly dis-infected. (II, Consensus)

i. In the case of a urinary or fecal accident, imme-diately terminate the visit and take appropriatemeasures to prevent recurrence during futurevisits. (II, Consensus)(1) If submissive urination was involved, this

will require suspending the animal’s visit-ing privileges, having the handler addressthe underlying cause, and then formallyreevaluating the animal’s suitability beforevisiting privileges are restored. (II,Consensus)


(2) In other situations, requiring that the han-dler be reeducated in attending to the ani-mal’s comfort may suffice. (II, Consensus)

(3) If repeated incidents of this nature occur,permanently withdraw the animal’s visit-ing privileges. (II, Consensus)

(4) In the case of vomiting or diarrhea, termi-nate the visit immediately and withdraw theanimal from visitation for a minimum of1 week,as discussed inV.1.b.(1). (II,Consensus)

j. Restrict the animal from patient lavatories. (II,Consensus)

k. Report any scratches, bites, or any other inap-propriate animal behavior to health care staffimmediately so that wounds can be cleanedand treated promptly.6 Later, report the inci-dent to the AVL and to public health or animalcontrol authorities, as required by local laws.(II, Consensus)(1) The visit should be immediately terminated

after any bite or scratch. (II, Consensus)(2) In the case of bites, intentional scratches,

or other serious, inappropriate behavior,permanently withdraw the animal’s visit-ing privileges. (II, Consensus)

(3) In the case of accidental scratches, con-sider the circumstances that contributedto the injury and take appropriate mea-sures to prevent similar injuries from oc-curring in the future. If measures cannotbe undertaken to reduce the risk of recur-rence, then visitation privileges should bewithdrawn. (II, Consensus)

(4) If it is determined that the handler’s behav-ior was instrumental in the incident, thenthe handler’s visitation privileges should beterminated until the AAI program managerhas addressed the situation. (II, Consensus)

l. Report any inappropriate patient behavior(eg, inappropriate handling, refusal to fol-low instructions) to the AVL. (II, Consensus)

VIII. Preparing animals for visits1. Require that every handler do the following:

a. Brush or comb the animal’s hair coat before avisit to remove as much loose hair, dander, andother debris as possible. (II, Consensus)

b. Keep the animal’s nails short and free of sharpedges. (II, Consensus)

c. If the animal is malodorous or visibly soiled,bathe it with a mild, unscented (if possible),hypoallergenic shampoo and allow the ani-mal’s coat to dry before leaving for the HCF.(II, Consensus)

d. Visually inspect the animal for fleas and ticks.(II, Consensus)

e. Clean the animal carrier before visits. (II,Consensus)

f. Maintain animal leashes, harnesses, and collarsvisibly clean and odor-free. (II, Consensus)

g. Use only leashes that are nonretractable and1.3 to 2 m (4 to 6 feet) or less in length. (II,Consensus)

h. Do not permit the use of choke chains orprong collars, which may trap and injure pa-tients’ fingers. (II, Consensus)

i. Identify an animal belonging to an AAI programwith a clean scarf, collar, harness or leash, tagor other special identifier readily recognizableby staff. (II, Consensus)

j. Provide a dog with an opportunity to urinateand defecate immediately before entering theHCF. (II, Consensus)(1) Dispose of any feces according to the pol-

icy of the HCF and practice hand hygieneimmediately afterward. (II, Consensus)

IX. Managing appropriate contact between animalsand people during visits

1. All animalsa. Obtain oral or, ideally, written consent from

the patient or his or her agent for the visit. (II,Consensus)

b. Require the handler to obtain oral permissionfrom other individuals in the room (or theiragents)before entering for visitation. (II, Consensus)

c. Ensure that people who have been identified(or have identified themselves) beforehand asbeing allergic to animals, or resistant to or un-comfortable in the presence of animals, arepointed out to the handler, along with instruc-tions to avoid these individuals. (II, Consensus)

d. Do not allow an animal to visit in rooms sharedby people with known or suspected fears ofanimals or allergies to animal saliva, dander,or urine.6 (IC, Consensus)

e. Restrict all visiting animals from entering thefollowing areas at all times:(1) Food preparation areas or carts(2) Medication preparation and storage areas

or carts(3) Operating rooms(4) Neonatal nurseries(5) Areas of patient treatment where the na-

ture of the treatment (eg, resulting in painfor the patient) may cause the animal dis-tress. This may be a particular concernfor a patient’s own animal.

(6) Other areas identified specifically by theHCF.8 (II, Consensus)

f. Restrict all animals from entering dialysis orburn units, except under special circumstances


and with the agreement of the patients’ physi-cian(s), the AVL, and the infection control staff.(II, Consensus)

g. Require the handler to prevent the animalfrom coming into contact with sites of invasivedevices, open or bandaged wounds, surgicalincisions or other breaches in the skin, or med-ical equipment.52,53 (IB, Consensus)

h. If the patient or agent requests that an animalbe placed on the bed, require that the handler:(1) Check for visible soiling of bed linens first.

(II, Consensus)(2) Place a disposable, impermeable barrier be-

tween the animal and the bed; throw the bar-rier away after each patient. (II, Consensus)

(3) If a disposable barrier is not available, a pil-lowcase, towel, or extra bed sheet can beused. Place such an item in the laundry im-mediately after use and never use it formultiple patients. (IB, Consensus)

2. AAI animalsa. Allow the animal to visit only with patients,

visitors, and staff who clearly express an inter-est, or with patients on whose behalf an agenthas expressed an interest. (II, Consensus)

b. Ensure that all potentially immunocompro-mised patients are assessed by their primaryhealth care providers to determine whether vis-iting with an animal would be appropriate, andthat this information is conveyed to the AVL,who will indicate to the handlers which patientsare ineligible for visitation. (II, Consensus)

c. Restrict AAI animals from visiting patients whoare in critical care or in isolation. (II, Consensus)

d. Instruct the handler to discourage patients andhealth care workers from shaking the animal’spaw. (II, Consensus)

e. Require the handler to prevent the animal fromlicking patients and health care staff.22,52,53 (IB,Consensus)

f. The feeding of treats to animals by health careworkers or patients is generally not recommen-ded; however, if the act is believed to have a sig-nificant therapeutic benefit for a particularpatient, then require that the handler:(1) Ensure that the animal has been trained to

take treats gently. (II, Consensus)(2) Provide the patient with appropriate treats

to give, avoiding unsterilized bones, raw-hides and pig ears, and other dehydratedand unsterilized foods or chews of animalorigin. (II, Consensus)

(3) Ensure that the patient practices hand hy-giene before and after presenting the treatto the animal. (II, Consensus)

(4) Instruct the patient to present the treatwith a flattened palm. (Unresolved issue,Consensus)

3. Patient-owned animalsa. Restrict a patient-owned animal from visiting the

patient in a critical care or isolation unit exceptunder special circumstances, with the agree-ment of the patient’s physician, the AVL, andthe infection control staff, and when arrange-ments can be made to control the visitationsituation to minimize the risk of transmissionof infectious organisms. (II, Consensus)

X. Contact tracing1. The facility should develop a system of contact

tracing that at a minimum requires animal han-dlers to sign in when visiting and ideally providesa permanent record of areas and/or room num-bers where the animal has interacted with pa-tients. (II, Consensus)

XI. Determining appropriate visit locations1. Individual HCFs are in the best position to decide

which locations are appropriate for animals in-teracting with patients, in consultation with theinfection control practitioner. (II, Consensus)

XII. Environmental cleaning1. Practice routine cleaning of environmental sur-

faces after visits.6 (II, Consensus)

The authors thank the many people who provided thoughtful feedback on and sugges-tions for the content of this document, including Steven Kruth, DVM, DACVIM, PhilArkow, BA, Jeff Bender, DVM, MS, Jennifer Calder, DVM, MPH, PHD, Radford Davis,DVM, MPH, John New, DVM, MPH, DACVPM, Debra Horwitz, DVM, DACVB, BeckyJankowski, RN, MS, Bonnie Beaver, DVM, MS, DACVB, Janice Seigford, DVM, DACVB,Amy Marder, VMD, CAAB, Jacqui Ley, BVSc, MACVS, and Deschler Cameron, DVM.

References

1. Barak Y, Savorai O, Mavashev S, Beni A. Animal-assisted therapy for

elderly schizophrenic patients: a one-year controlled trial. Am J

Geriatr Psychiatry 2001;9:439-42.

2. Sobo EJ, Eng B, Kassity-Krich N. Canine visitation (pet) therapy: pilot

data on decreases in child pain perception. J Holist Nurs 2006;24:51-7.

3. Nelson JP. Being in tune with life: complementary therapy use and well-

being in residential hospice residents. J Holist Nurs 2006;24:152-61.

4. Colombo G, Buono MD, Smania K, Raviola R, De Leo D. Pet therapy

and institutionalized elderly: a study on 144 cognitively unimpaired

subjects. Arch Gerontol Geriatr 2006;42:207-16.

5. McCabe BW, Baun MM, Speich D, Agrawal S. Resident dog in the

Alzheimer’s special care unit. West J Nurs Res 2002;24:684-96.

6. Sehulster L, Chinn RY. CDC, HICPAC. Guidelines for environmental

infection control in health-care facilities: recommendations of the

CDC and the Healthcare Infection Control Practices Advisory Com-

mittee (HICPAC). MMWR Recomm Rep 2003;52:1-42.

7. American Veterinary Medical Association. Wellness guidelines for

animals in animal-assisted activity, animal-assisted therapy and resident

animal programs, 2007. Available from: http://www.avma.org/issues/

policy/animal_assisted_activity.asp. Accessed January 8, 2007.

8. Yamauchi T, Olmsted RN. Animal-assisted therapy. In: Olmsted RM,

editor. APIC infection control and applied epidemiology: principles

and practice. St Louis: Mosby; 1996. p. 97-1-5.

http://www.avma.org/issues/policy/animal_assisted_activity.asp

http://www.avma.org/issues/policy/animal_assisted_activity.asp


9. Delta Society. Standards of practice for animal-assisted activities and

animal-assisted therapy. Renton (WA): Delta Society; 2003.

10. The pathological cat [editorial] J Am Med Assoc 1906;47:209.

11. Chang HJ, Miller HL, Watkins N, Arduino MJ, Ashford DA, Midgley G,

et al. An epidemic of Malassezia pachydermatis in an intensive care

nursery associated with colonization of health care workers’ pet

dogs. N Engl J Med 1998;338:706-11.

12. Drusin LM, Ross BG, Rhodes KH, Krauss AN, Scott RA. Nosocomial

ringworm in a neonatal intensive care unit: a nurse and her cat. Infect

Control Hosp Epidemiol 2000;21:605-7.

13. Scott GM, Thomson R, Malone-Lee J, Ridgway GL. Cross-infection be-

tween animals and man: possible feline transmission of Staphylococcus

aureus infection in humans? J Hosp Infect 1988;12:29-34.

14. Stryker-Gordon R, Beall N, Anderson RK. Fact & fiction: health risks

associated with pets in nursing homes. J Delta Soc 1985;2:73-4.

15. Lerner-DurJava L. Pet visitation is an infection control issue? Am J

Infect Control 1994;22:112.

16. Robb S, Miller R. Pilot study of pet-dog therapy for elderly people in

long-term care. Pittsburgh (PA): VA Medical Center; 1982.

17. Pet therapy hazards [news report]. Anthrozoos 1987;1:258.

18. Lefebvre SL, Waltner-Toews D, Peregrine A, Reid-Smith R, Hodge L,

Weese JS. Characteristics of programs involving canine visitation of hospi-

talized people in Ontario. Infect Control Hosp Epidemiol 2006;27:754-8.

19. Lefebvre SL, Waltner-Toews D, Peregrine AS, Reid-Smith R, Hodge L,

Arroyo LG, et al. Prevalence of zoonotic agents in dogs visiting hospi-

talized people in Ontario: implications for infection control. J Hosp

Infect 2006;62:458-66.

20. Lefebvre SL, Arroyo LG, Weese JS. Epidemic Clostridium difficile strain

in hospital visitation dog [letter] Emerg Infect Dis 2006;12:1036-7.

21. Lefebvre SL, Arroyo LG, Rousseau J, Weese JS. Clostridium difficile:

evidence for zoonotic potential [abstract]. Abstracts from the Second

International Clostridium difficile Symposium; June 6–9, 2007. Maribor,

Slovenia: Koda Press; 2007.

22. Lefebvre SL. MRSA risk with animal-assisted activity and therapy pro-

grams. Conference Notes of the 144th Annual AVMA Convention,

Washington, DC, July 13–18, 2007. Schaumburg (IL): American Veter-

inary Medical Association; 2007.

23. Enoch DA, Karas JA, Slater JD, Emery MM, Kearns AM, Farrington M.

MRSA carriage in a pet therapy dog. J Hosp Infect 2005;60:186-8.

24. Lefebvre SL, Weese JS. Characterizing opportunities for spreading

pathogens through dog visiting programs in Ontario healthcare facili-

ties [abstract]. Am J Infect Control 2007;35:e205-6.

25. Yamauchi T, Baeyens MM, McCoy J, Carter D. The microflora of

animals used in hospital pet therapy [abstract]. Clin Res 1984;32:

8804.

26. Boyce JM, Pittet DH, HICPAC, Society for Healthcare Epidemiology of

America, Association for Professionals in Infection Control, Infectious

Diseases Society of America, Hand Hygiene Task Force. Guideline for

hand hygiene in health-care settings: recommendations of the Health-

care Infection Control Practices Advisory Committee and the HIC-

PAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control

Hosp Epidemiol 2002;23(12 Suppl):S3-S40.

27. Wells EV, Boulton M, Hall W, Bidol SA. Reptile-associated salmonello-

sis in preschool-aged children in Michigan, January 2001–June 2003.

Clin Infect Dis 2004;39:687-91.

28. Centers for Disease Control and Prevention. Reptile-associated sal-

monellosis—selected states, 1998–2002. MMWR Morb Mortal Wkly

Rep 2003;52:1206-9.

29. Stam F, Romkens TE, Hekker TA, Smulders YM. Turtle-associated

human salmonellosis. Clin Infect Dis 2003;37:e167-9.

30. Sharma VK, Kaura YK, Singh IP. Frogs as carriers of Salmonella and

Edwardsiella. Antonie Van Leeuwenhoek 1974;40:171-5.

31. Ostrowski SR, Leslie MJ, Parrott T, Abelt S, Piercy PE. B-virus from pet

macaque monkeys: an emerging threat in the United States? Emerg

Infect Dis 1998;4:117-21.

32. Dienstag JL, Davenport FM, McCollum RW, Hennessy AV, Klatskin G,

Purcell RH. Nonhuman primate-associated viral hepatitis type A: sero-

logic evidence of hepatitis A virus infection. JAMA 1976;236:462-4.

33. Swanson SJ, Snider C, Braden CR, Boxrud D, Wunschmann A, Rudroff

JA, et al. Multidrug-resistant Salmonella enterica serotype Typhimurium

associated with pet rodents. N Engl J Med 2007;356:21-8.

34. Centers for Disease Control and Prevention. Outbreak of multidrug-

resistant Salmonella typhimurium associated with rodents purchased at

retail pet stores—United States, December 2003–October 2004.

MMWR Morb Mortal Wkly Rep 2005;54:429-33.

35. Woodward DL, Khakhria R, Johnson WM. Human salmonellosis asso-

ciated with exotic pets. J Clin Microbiol 1997;35:2786-90.

36. Craig C, Styliadis S, Woodward D, Werker D. African pygmy hedge-

hog–associated Salmonella tilene in Canada. Can Commun Dis Rep

1997;23:129-31.

37. Guarner J, Johnson BJ, Paddock CD, Shieh WJ, Goldsmith CS, Reynolds

MG, et al. Monkeypox transmission and pathogenesis in prairie dogs.

Emerg Infect Dis 2004;10:426-31.

38. Centers for Disease Control and Prevention. Outbreaks of Escherichia

coli O157:H7 associated with petting zoos—North Carolina, Florida,

and Arizona, 2004 and 2005. MMWR Morb Mortal Wkly Rep 2005;

54:1277-80.

39. Clark CG. The hazards of pet therapy? Ontario Dis Surveill Rep 1986;

7:1-3.

40. Hill SL, Cheney JM, Taton-Allen GF, Reif JS, Bruns C, Lappin MR. Prev-

alence of enteric zoonotic organisms in cats. J Am Vet Med Assoc

2000;216:687-92.

41. Streitel RH, Dubey JP. Prevalence of Sarcocystis infection and other in-

testinal parasitisms in dogs from a humane shelter in Ohio. J Am Vet

Med Assoc 1976;168:423-4.

42. Kazacos KR. Gastrointestinal helminths in dogs from a humane shelter

in Indiana. J Am Vet Med Assoc 1978;173:995-7.

43. Blagburn BL, Lindsay DS, Vaughan JL, Rippey NS, Wright JC, Lynn RC,

et al. Prevalence of canine parasites based on fecal flotation. Compend

Cont Educ Pract Vet 1996;18:483-509.

44. Seah SK, Hucal G, Law C. Dogs and intestinal parasites: a public health

problem. Can Med Assoc J 1975;112:1191-4.

45. Wright JC, Amoss RT. Prevalence of house soiling and aggression in

kittens during the first year after adoption from a humane society.

J Am Vet Med Assoc 2004;224:1790-5.

46. Overall KL. Clinical behavioral medicine for small animals. St. Louis:

Mosby; 1997. p. 48-50, 283-4.

47. Tucker MT, editor. The Pet Partners team training course manual. 6th

ed. Belleview (WA): Delta Society; 2005.

48. Weese JS, Rousseau J, Arroyo L. Bacteriological evaluation of com-

mercial canine and feline raw diets. Can Vet J 2005;46:513-6.

49. Finley R, Ribble C, Aramini J, Vandermeer M, Popa M, Litman M, et al.

The risk of salmonellae shedding by dogs fed Salmonella-contaminated

commercial raw food diets. Can Vet J 2007;48:69-75.

50. Lefebvre SL, Waltner-Toews D, Weese JS. Should dogs that participate

in animal-assisted activity and therapy programs be prohibited from

consuming raw diets? [abstract]. Proceedings of the Joint Symposium

of the Association of American Veterinary Medical Colleges/American

Schools of Public Health, Atlanta, GA, April 22-24, 2007. Atlanta (GA):

American Schools of Public Health; 2007.

51. Centers for Disease Control and Prevention. Infection control guid-

ance for the prevention and control of influenza in acute-care facilities,

2007. Available from: http://www.cdc.gov/flu/professionals/infection

control/pdf/flu-infectioncontrol-hcfacilities.pdf. Accessed April 26,

2007.

52. Octavio J, Rosenberg W, Conte JE Jr. Surgical-wound infection with

Pasteurella multocida from pet dogs. N Engl J Med 2001;345:549.

53. Chikwe J, Bowditch M, Villar RN, Bedford AF. Sleeping with the

enemy: Pasteurella multocida infection of a hip replacement. J R Soc

Med 2000;93:478-9.

http://www.cdc.gov/flu/professionals/infectioncontrol/pdf/flu-infectioncontrol-hcfacilities.pdf

http://www.cdc.gov/flu/professionals/infectioncontrol/pdf/flu-infectioncontrol-hcfacilities.pdf