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After Hours Standing Orders for Antiviral Prophylaxis Exposures to Herpes B and SIV/SHIV/HIV After an NHP related injury/exposure, notify the shift supervisor and START scrubbing with soap and water (bite, scratch, laceration or needle stick) or flushing with water (mucosal exposure) IMMEDIATLY for 15 minutes (SOP HH-7) 1) 2) Contact one of the following individuals: Jenny Short cell 530-400-3379 Sarah Davis cell 530-574-4557 Greg Hodge cell 530-304-5585 Jaleh Janatpour cell 916-716-5884 home 530-756-6300 The exposed employee MUST contact the occupational health physician 24hr phone number (530) 797-6691 3) To the occupation health physician state the specific circumstances of the injury and the health status of the animal, including involvement in any research studies such as SIV, other infectious agents, and recent medications given to the involved animal. 4) Do not delay immediate scrubbing or flushing of the exposure site a full 15 minutes per SOP# HH-7. THIS IS EXTREMELY CRITICAL TO THE OUTCOME! 5) Contact the on-call veterinarian, as posted in 1402, to obtain animal samples as soon as possible per SOP HH-09. 6) If directed to do so by the physician follow Dr. Belcourt’s Standing Orders to provide the appropriate antiviral medication(s) that are kept secured in a lock box in the Research Services Office. If antivirals are indicated, provide to the injured employee the entire intact bottle(s) of appropriate medication(s), documenting as follows. 7) Document implementation of standing orders in the “Antiviral Drug Log Binder” (a blue 3-ring binder) which is maintained in the Research Services Office. 8) Remove the Rx # sticker from the bottle being provided to the injured employee and place the sticker onto a blank form. There are separate forms for the “Standing Order for Valacyclovir following potential Herpes B exposure” and the “Standing order for Combivir for post exposure prophylaxis potential HIV/SIV/SHIV exposure” in the binder. Complete the required forms per the Revised 9/6/2016, Greg Hodge physician orders, including the CNPRC after hours NHP related injury log (in the front of the binder. 9) If providing on site antiviral medications to the injured employee per Standing Orders, also provide to the injured employee a copy of the relevant patient information for Valtrex (Valacyclovir) and/or Combivir, as applicable. Copies are in the binder. 10) Complete the “CNPRC After Hours NHP Related Injury Log” in the binder, documenting that the employee was provided with the specific antiviral meds or that the employee has declined the meds at this time. Include the name of the physician spoken to. 11) Instruct the employee to report to Occupational Health by calling 530-752-6051 the very next business day to schedule an appointment. 12) In an emergency involving more severe injury the employee may need to be transported to Sutter Davis Emergency Room, located off Covell Blvd. at 2000 Sutter Place. Call 9-1-1 (campus phone) or campus emergency 530-752-1234 for any emergency or serious injury. 13) For employees who are being sent to Sutter, if possible provide a copy of “To Sutter Emergency Room Physician and Triage Staff.” This is a summary of Herpes B and NHP exposure information. Copies are in the binder. 14) If it is a serious injury follow emergency procedures to call 9-1-1. Also contact one or more of the following individuals: Jenny Short Kari Christe, DVM Jeff Roberts, DVM Home 530-756-6300 Home 916-419-3964 Cell 530-908-2475 Cell 530-400-3379 Pager 530-750-8013 Valacyclovir (Valtrex) Antiviral Prophylaxis guidelines for potential Herpes B Virus exposures B virus exposure includes macaque bites, macaque scratches or contact to the mucous membranes or non-intact skin with macaque body fluids/ secretions, particularly ocular, oral or genital secretions or nervous system tissue, and also direct contact with material contaminated by macaques (such as cages surfaces, sharps, instruments or equipment). The usual dosage of valacyclovir (Valtrex) is 1 gm, 1 tablet 3 times daily until further consultation with the Occupational Health Physician. Evaluation of the exposure is according to following guidelines per the B Virus Working Group recommendations¹: (Follow occupational health physician’s orders) Valacyclovir Prophylaxis recommended for: Skin exposure (with loss of skin integrity) or mucosal exposure (with or without injury) to a high risk source (such as a macaque that is ill, immunocompromised, or known to be shredding virus or that has lesions compatible with B virus disease). Inadequately cleaned skin exposure (with loss of skin integrity) or mucosal exposures (with or without injury). Laceration of the head, neck or torso. Deep puncture bite. Needle stick associated with tissue or fluid from the nervous system, lesions suspicious for B virus, eyelids or mucosa. Puncture or laceration after exposure to objects (a) contaminated either with fluid from monkey oral or genital lesions or with nervous system tissues, or (b) known to contain B virus. Valacyclovir Prophylaxis considered for: Mucosal splash that has been adequately cleaned. Laceration, bite (with loss of skin integrity), that has been adequately cleaned. Needle stick involving blood from an ill or immunocompromised macaque. Puncture or laceration occurring after exposure to objects (a) contaminated with body fluid (other than that from a lesion – see Valtrex recommended above), or (b) potentially infected cell culture. Valacyclovir Prophylaxis NOT recommended for: Skin exposure in which the skin integrity remains intact. Exposure associated with non-macaque species of nonhuman primates. Lamivudine / Zidovudine (Combivir) per standing Order for SIV/HIV/SHIV Exposure Currently Combivir is recommended for; A bite or scratch from an SIV or SHIV infected nonhuman primate. Splash to eyes, nose, mouth, mucous membranes or non-intact skin with body fluids from an SIV or SHIV infected nonhuman primate or from SIV, HIV or SHIV infected nonhuman primate tissue, fluid or culture. Laceration, puncture wound or scratch from a contaminated object such as a scalpel cut during a necropsy procedure on SIV or SHIV infected nonhuman primate. Injury Follow-up Procedures Follow SOP HH-9 for immediate collection of animal samples for Herpes B testing. After following the procedures described above, it is important for the injured employee to report to the Research Services Manager of Operations in room 1904 (530) 752-0438 AND to Occupational Health Services the very next work day. Occupational Health Services is located at Cowell Hall, California Ave. on campus; phone 530-752-6051. Normally the employee should contact the Research Services Manager of Operations who will call Occupational Health to verify that an Occupational Health Physician is available to see the employee. Refer to SOP HH-7 and SOP HH-9 for complete procedures. Important Emergency Procedures If the injury is severe or profusely bleeding, call 9-1-1 from a campus phone or (530) 7521234 or (530) 753-1230 from a cell phone or report to Sutter Health Emergency Room as appropriate. For serious primate related injuries, provide emergency medical professionals with afterhours home contact phone numbers as above. Time permitting provide the “To Sutter Emergency Room Physician and Triage Staff” document and the references below to the first responders. References National B virus Resource Lab, Georgia State University Viral Immunology Lab, Emergency Phone for Dr. Julia Hilliard, Director Office 404-413-6560 Cell 404-556-9451 http://www2.gsu.edu/~wwwvir/ Recommendations for Prevention of and Therapy for Exposure to B Virus (Cercopithecine Herpesvirus 1) Cohen, Jeffrey I, et al and the B Virus Working Group, Clinical Infectious Disease 2002:35: 1191-1203 http://www.cdc.gov/ncidod/diseasesbvirus.pdf