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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 • • • • • • Zoonotic pathogen exposure Vectors of human pathogens Bites/scratches Allergies Fear Disruption Animals in LTCF • • • • • Resident animals Animal assisted therapy Pet visitation Service animals Visiting programs Types of contact Duration of contact Animals in LTCF • • • • • 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 • • • • • • 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 ▫ ▫ ▫ ▫ 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 • • • • • Salmonella: 3% ESBL E. coli: 4% Giardia: 7% Toxocara canis: 2% Pasteurella canis/multicida: 22%/7% • • • • • 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 ▫ ▫ ▫ ▫ 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 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 ▫ ▫ ▫ ▫ 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 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 ▫ ▫ ▫ ▫ Undergo formal hospital volunteer training Annual influenza vaccination Training program regarding visitation activities Syndromic restriction: self screening • Pre-visit ▫ ▫ ▫ ▫ 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 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 • • • • 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