Handling and Housing Patients with Zoonotic Infections

Introduction

Zoonotic diseases pose a potential risk to faculty, house officers, staff, students, visitors, and volunteers of the NC State Veterinary Hospital (VH). Communication and diligent hand washing are essential for preventing potential transmission within the hospital.

The following protocols must be followed when a zoonotic disease is diagnosed or is included on the list of potential differential diagnoses for a patient of the VH.  Furthermore, if at any point there is a personnel exposure risk, the following SOP must be followed: “Protocol for Addressing Potential Zoonotic Disease Exposure”. This applies anytime personnel or visitors have come into contact with the animal directly, or in contact with potentially infected samples, in the absence of appropriate PPE or handling protocols.  It also applies to cases where there is a strong potential that the animal has a zoonotic disease or the animal has tested positive to a zoonotic disease.

Tag / sticker system

• One of the two tags / labels listed below must be used anytime you are testing for a zoonotic disease or anytime you suspect a patient may have a zoonotic disease.
• Tags / Labels must be used as follows:
  • On animal holding areas (cage/run/stall/carrier, etc)
  • On the medical record.
  • On or with any samples, slides, or specimens.
  • On the animal’s body and any material used to cover / secure the animal if deceased.
  • Stickers on samples, slides, and body upon death; may at times be different than the sticker on the animal holding area and medical record.  Direct exposure to clinical specimens may have a different exposure risk than that of staff handling and treating the patient while alive.

• Example of appropriate use of the “Low Risk Zoonotic” sticker:
  • The client of an admitting patient asked the senior clinician to test for a zoonotic disease. The senior clinician did not think this patient had the zoonotic disease but agreed to run the test for the clients benefit.
  • This patient can be identified using the “Low Risk Zoonotic” sticker and it can be handled and housed per normal handling and housing guidelines. It does not require the use of Restriction or Isolation protocols.
  • Animal holding areas, the medical record, samples, etc should be labeled with the “Low Risk Zoonotic” sticker because it is being tested for a zoonotic disease and this provides appropriate communication to all hospital areas and personnel who may come into contact.

General Instructions

• Zoonotic potential identified at the time of first contact by receptionist or CT:

Contact the senior clinician, who will determine whether the patient is in fact a zoonotic risk. The senior clinician will discuss the case with the technician supervisor to determine if the animal needs to be immediately placed in isolation or another type of restriction and to determine the most appropriate transportation route.

• Zoonotic potential identified in the examination room:
• Keep the animal and all personnel in the examination room and contact the senior clinician, who will determine whether the patient is in fact a zoonotic risk. The senior clinician will discuss the case with the technician supervisor to determine if the animal needs to be immediately placed in isolation or another type of restriction and to determine the most appropriate transportation route.
  • All personal attire and equipment will be evaluated for possible contamination. When in doubt: disinfect, change, or dispose.
  • The supervisor will assign cleaning staff to disinfect the room per cleaning protocols.
• Place a sign on the room to prevent anyone else from entering.  Signs are available in each examination room.

• Zoonotic potential identified after admission:

If moving within the hospital at the time it is determined the animal potentially poses a zoonotic risk, either place the animal directly in isolation or if you are unsure, return the animal to its current holding area and contact the treating technician assigned to the patient, the technician supervisor, and the senior clinician.

• All personal attire and equipment will be evaluated for possible contamination. When in doubt: disinfect, change, or dispose.
• The supervisor will assign cleaning staff to disinfect all potentially affected areas per cleaning protocols.
• The supervisor is responsible for contacting the Director of Small Animal Clinical Services or the Equine and Farm Animal Operations Manager.
  • These two individuals are responsible for communicating with all potentially affected areas to determine appropriate action, including disinfection and communication.

Steps that must be taken when a zoonotic infection is included on the list of potential differential diagnoses

General Communication

1. Identify the animal holding area, medical record, samples, etc with the “High Risk Zoonotic” tag/sticker (see risk tag chart above).
2. Inform the senior clinician, area technician staff, and technician supervisor.
   1. If they are not available or if you have questions, contact the Director of Small Animal Clinical Services or the Equine and Farm Animal Operations Manager.
   2. The technician staff are responsible for implementing appropriate PPE setup and supplies, i.e. Restriction/Isolation if warranted. This should be determined by referencing the Suspect Infectious Disease Chart.
3. Start a Contact Log that will stay with the patient and be signed by any individual that comes into contact with the patient or in contact with contaminated materials / samples.
4. Specimens, samples, and/or the body must be labeled with the “High Risk Zoonotic” sticker.

Handling

1. If the patient is housed in isolation, the isolation protocol is instituted and supersedes the protocol listed below.
2. Any person handling the animal should wear gloves and other appropriate PPE depending on the housing / handling requirements for that particular disease / infection.
3. Hands must be washed after handling the animal and after glove removal.
4. All non-disposable supplies must be contained and properly disinfected following use. Area technicians can be contacted to assist.

Transport and Housing

• If the patient is housed in isolation, the isolation protocol is instituted and supersedes the protocol listed below.
• The patient will be removed from its housing area only when necessary.
• Small animal patients must be transported on a cart, dedicated to that patient.
• Equine and farm animal patients should be transported via a supervisor approved route that avoids out-patient areas and is promptly disinfected following transport.
• Appropriate PPE must be worn by all personnel who come into contact with the animal.
• The technician or supervisor responsible for areas, where the patient is treated, shall be informed immediately so the area can be properly disinfected.

Protocol for Admitting or Receiving Animals with DVM-Suspected Zoonotic Infection

When a patient is admitted that the RDVM suspects has a zoonotic infection, the animals cage/stall should be labelled with a high risk tag and the patient should be handled, housed, and considered to have a potentially zoonotic infection until the house officer discusses the case with a senior clinician and determines the appropriate risk.

Protocol for Re-admitting Animals Previously determined to have a Zoonotic Infection

Animals that have been diagnosed with a zoonotic infection should be identified as such via the electronic medical record prior to being discharged.  Upon re-admission the patient should be handled as high risk until one of the following criteria are met:

• If, in the judgment of the attending senior clinician, there is resolution of the patient’s infection and clinical signs, appropriate treatment has occurred, and/or a sufficient length of time has passed to suggest the animal is no longer contagious.
• A negative diagnostic test from a representative sample is finalized in the patient’s record.
• The infected tissue has been removed and the site is healed as determined by a VH clinician.

If one of the above criteria are met, clinicians must note those involved in the discussion, note the outcome in the medical record, inform the technician supervisor, and electronically inform a member of the infectious disease committee, prior to handling the animal normally.

Examples include, but are not limited to: Salmonella, Mycobacterium, Leptospira