Download Animals in longterm care facilities

Animals in longterm care facilities
J Scott Weese DVM DVSc DipACVIM
We are not a population of people, in populations
of dogs, cats, horses…
We are a population of animals.
Veterinary Practice News 2006
The Good
The Bad
• Health benefits
• Emotional benefits
• Enjoyment
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Zoonotic pathogen exposure
Vectors of human pathogens
Bites/scratches
Allergies
Fear
Disruption
Animals in LTCF
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Resident animals
Animal assisted therapy
Pet visitation
Service animals
Visiting programs
Types of
contact
Duration of
contact
Animals in LTCF
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Resident animals
Animal assisted therapy
Pet visitation
Service animals
Visiting programs
Legal
protection
Handler
knowledge/s
kill
Number of
residents
exposed
Species
Ability to
control
contact/movem
ent
Health and
behaviour
assessment
Animal-associated sources of infection
• Feces
▫ Direct
▫ Indirect
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Mucous membranes
Skin
Infected sites
Food/treats
Bites/scratches
External parasites
State of Programs, Ontario
• Survey of all Ontario hospitals, 2004
▫ 96.5% response rate
• Parallel survey of visitation dog owners
• 90% (201/223) hospitals permitted animal
visitation
▫ Only 20% of hospitals expressed an interest in free
testing of dog
• 27% of facilities not aware of all origins of
animals
S Lefebvre et al, Infect Control Hosp Epidemiol 2005
Longterm care?
Observational Study
• Temperament issues
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Husky too aggressive to examine
Pomeranian bite on upper lip
Chihuahua bite on hand*
Labrador scratch on arm*
• 0/75 healthcare workers that handled dogs
performed hand hygiene before or after
• ~4% (n>400) of patients practiced hand hygiene
before handling dogs
▫ Only 5% after
• About half of observed dogs licked patients
• ~25% of handlers held patients’ hands
▫ <4% of handlers performed hand hygiene
between patients
Do animals involved in
visitation programs carry
zoonotic pathogens?
Cross-Sectional Study
• 102 active visitation dogs in Ontario, 2004
• 80% carried at least one potentially zoonotic
pathogen
Lefebvre et al J Hosp Infect 2006
• C. difficile: 58%
▫ Including ribotype 027/NAP1
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Salmonella: 3%
ESBL E. coli: 4%
Giardia: 7%
Toxocara canis: 2%
Pasteurella canis/multicida: 22%/7%
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Group A streptococci: 0%
MRSA: 0%
VRE: 0%
Ringworm: 0%
Cryptosporidium spp: 0%
Do animals acquire pathogens
during visitation?
Are they transiently colonized
with any pathogens?
Longitudinal Study
• Dogs enrolled before starting visitation careers
▫ Healthcare facilities (n=100)
▫ Other facilities (ie schools) (n=100)
• Monthly sampling for MRSA, VRE, E. coli,
Salmonella, C. difficile
Lefebvre et al, 2009
Results
• 9% of exposed dogs acquired MRSA
▫ 1% unexposed
• Most described as ‘lickers’
• Relevance unclear, but potentially a risk
• All naturally decolonized by next visit
- C. difficile acquisition by
- 15 unexposed dogs
- 28 exposed dogs (P=0.025)
• 1 exposed dog acquired VRE
• MRSA risk factors
▫ Healthcare centre visitation: OR 6.3
▫ Visitation of children: OR 7.1
• C. difficile risk factors
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Healthcare contact: OR 3.3
Visitation of children: OR 3.5
Antimicrobial treatment: OR 2.2
Antimicrobial treatment of someone in the house: OR
3.2
Nested Case-Control Study
• Positive/negatives in healthcare group
• MRSA
▫ Licked patients: OR 13.5
▫ Fed treats by patients: OR 12.3
• C. difficile
▫ Licked patients: OR 2.9
▫ Sat on beds: OR 2.9
▫ Ate feces: OR 0.12
Can animals act as ‘mechanical
vectors’?
• Shadowing study
▫ MRSA from coat of 1/25 (4%) dogs after visitation
in longterm care facility
▫ Dog not colonized
Lefebvre et al, J Hosp Infect, 2009
Do visitation animals actually
transmit disease?
There have been no reported outbreaks of
disease attributed to visitation programs…..
There have been no reported outbreaks of
disease attributed to visitation programs…..
but would the current system
realistically detect animal
involvement in disease?
Recommendations
• Species
▫ Domesticated species
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Good and predictable temperament
Good knowledge about infectious disease carriage
Ability to test/assess
Litter/house trained
Living in households
▫ Dogs…….cats
• Sources
▫ Not from shelters, pounds
▫ In household for at least 6 months
• Age
▫ Cats: > 1 year
▫ Dogs: > 2 years
• Temperament
▫ Passed objective, standard temperament test
conducted by trained personnel
▫ Repeated every 3 years
• Animal health screening
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Rabies vaccination
Annual veterinary examination
No deworming recommendations
No specific pathogen screening (ie MRSA,
Salmonella …)
• Diet
▫ No raw food or treats
▫ Restricted for > 1 week following
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Diarrhea
Vomiting
Sneezing, coughing
Antimicrobial, immunosuppressive therapy
Skin disease, SSTI
Potentially painful disorders
Fleas, external or internal parasites
• Temporary animal removal (re-test)
▫ Negative behavioural changes since last
temperament test
▫ Fearful response noted during visitation
▫ Loss of sight or hearing
▫ >6 month lapse in visitation
• Permanent animal removal
▫ Any bite
▫ Any aggressive behaviour
• Handlers
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Undergo formal hospital volunteer training
Annual influenza vaccination
Training program regarding visitation activities
Syndromic restriction: self screening
• Pre-visit
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Self-screen pets (syndromic)
Check for external parasites
Bath if visibly soiled coat
Clean leash/collar
 Leashed < 2 metres in length
▫ Method to identify animals (ie scarf)
• Visitation procedures
▫ Hand hygiene
▫ Proper contacts
 Safety, disease transmission
▫ Only on beds with impermeable, disposable
barrier
▫ No contact with invasive devices, wounds,
bandages…
▫ No visitation of patients under enhanced
precautions
▫ No visitation when patient is eating
▫ Explicit patient (and roommate) permission before
entering room
 Physician designation?
▫ Restrict to 1 hour (dog fatigue)
▫ No entrance to
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ICU
Food preparation areas
Medication preparation areas
OR
Isolation
Neonatal nurseries
Potentially frightening areas
• Hand hygiene
▫ Patients: Before AND after animal contact
▫ Handlers: Between rooms
▫ Handlers carry hand sanitizer
• Contact tracing
Guideline Status
http://jb.asm.org/content/vol191/issue17/cover.dtl
Food
Water
Endogenous
microflora
Pet therapy
Visitors
Hospital
environment
HCW hands
Infected/colonized
patient
Pepin et al, CMAJ, 2004.
Miller et al 2011
Long-term care
• Relatively limited information
• Clearly….
▫ Highly susceptible population
 Age, antimicrobials, comorbidities…
▫ Infection control and hygiene challenges
▫ Close contact with acute care facilities
LTCF questions
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What is the incidence of disease?
Why are there not more reported outbreaks?
What is the prevalence of colonization?
Does the epidemiology of colonization and
disease differ from acute care/community?
• Do LTCF seed C. difficile into acute care
facilities
▫ Or vice versa?
• Are interventions needed in LTCFs?
▫ If so…what?
The End