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Standard Operating Procedures for Working with Laboratory Primates Harvard Medical Area Center for Animal Resources and Comparative Medicine Contents: Zoonoses ........................................................................................................................................................... 2 Prevention of exposure .................................................................................................................................. 2 Animal handling ............................................................................................................................................. 2 Review of zoonotic diseases of nonhuman primates .................................................................................... 3 Blood borne parasites .................................................................................................................................... 4 Tuberculosis .................................................................................................................................................. 4 Herpes B (Herpesvirus simiae) ...................................................................................................................... 5 Need more information? ................................................................................................................................ 6 Protective equipment and safety practices ....................................................................................................... 6 Purpose ......................................................................................................................................................... 6 General Information ....................................................................................................................................... 6 Compliance .................................................................................................................................................... 7 Responsible Persons and Enforcement ........................................................................................................ 7 Work clothing and work shoes ....................................................................................................................... 7 Personal protective equipment ...................................................................................................................... 7 Personal Hygiene .......................................................................................................................................... 8 Training .......................................................................................................................................................... 8 Post exposure management of macaque bites and scratches ......................................................................... 8 Examination and culturing of nonhuman primate .......................................................................................... 9 Injuries on nights and weekends ................................................................................................................. 10 Postexposure monitoring ............................................................................................................................. 10 Directory for Medical Care of Monkey Bites and Scratches............................................................................ 10 Harvard Medical Area (Monday – Friday, 9 AM – 4 PM)............................................................................. 10 Brigham and Women’s Hospital Occupational Heath Services (Monday – Friday, 7:30 AM – 4:30 PM) ... 10 Nights, Weekends, Holidays ........................................................................................................................ 10 Infectious Disease Consultant ..................................................................................................................... 11 ARCM Veterinary Staff ................................................................................................................................ 11 NIH B Virus Resource Laboratory ............................................................................................................... 11 References ...................................................................................................................................................... 11 What to do if you are injured ........................................................................................................................... 11 1 Last printed 5/14/2017 5:49:00 AM Zoonoses Zoonoses are diseases which humans contract from animals. Monkeys pose a particular hazard to animal care workers because bites, scratches and contact with feces occur frequently during routine husbandry procedures and because humans and monkeys are susceptible to many of the same pathogens. Some primate zoonoses cause treatable but potentially debilitating illness (e.g. Shigella, campylobacter diarrhea) while others may be fatal (e.g. Herpes B infection). Monkeys are also susceptible to many human diseases. Devastating losses have occurred when infected humans transmit tuberculosis and measles to captive primates. These notes will discuss general principles that animal care workers should follow to avoid infection. Clinical features of the common zoonoses and the diseases that people can transmit to monkeys will be discussed. Prevention of exposure Personal hygiene and work practices Bacteria and viruses may be eaten, inhaled or injected by animal bites or contaminated needles. Intact skin is a good barrier against infection. Most bacteria and viruses are killed by soap and water. Wear appropriate protective clothing. Use disposable gloves and masks when handling monkeys or changing cages. Do not bring work clothes or shoes home. Change soiled clothing promptly. Don’t use needles and syringes unless you have been trained. Dispose of used needles promptly and safely. Do not recap needles. Be familiar with any special protocols regarding needle handling that have been developed for your area. Observe personal hygiene. Wash hands carefully and frequently. Remove laboratory jackets before eating. Take care of injuries promptly. Report to the nurse or supervisor as soon as possible after an injury. Be aware of clinical signs of illness in yourself. Report illness to the nurse or your supervisor. This is important for your own protection, for the health of your coworkers, and for the health of the monkeys Animal handling Follow appropriate monkey handling techniques. Use chemical restraint for any invasive procedure. 2 Last printed 5/14/2017 5:49:00 AM Do not handle monkeys unless you have been appropriately trained. Learn to anticipate monkey behavior; learn the behavior of individual monkeys that you work with. Ask for help from the animal’s regular attendant. Learn the behavior patterns of monkeys in your area. Be calm when working around monkeys. Avoid shouts, direct stares and other provocative gestures that might antagonize them. Be vigilant around monkeys. Never enter a group cage of monkeys unless you have been properly trained and have the proper equipment. Anticipate aggressive behavior by monkeys. Use extra caution when capturing or examining conscious monkeys. Use heavy leather gloves or nets for protection against bites and scratches when hand-catching conscious monkeys. Be aware of clinical signs of illness in monkeys and notify clinical veterinarians about sick animals. Observe posted warnings and signs. Review of zoonotic diseases of nonhuman primates Gastrointestinal zoonoses Monkeys may harbor bacteria that cause debilitating diarrhea in people. Most infected animals are acutely ill and very weak. Monkeys may also shed large numbers of bacteria in their feces without serious illness. People may also shed these bacteria asymptomatically. Diagnosis of all of these infections is by culture of the feces. Campylobacteriosis Campylobacter jejuni is common in all species of nonhuman primates. Asymptomatic shedding is common. Food and water are also common sources of campylobacter infections. The clinical signs of campylobacter in monkeys are variable. Some monkeys will have mild diarrhea that resolves without treatment. Other monkeys will have severe diarrhea that causes weight loss and dehydration. Blood and mucous may be seen in feces. Treatment involves supportive care (oral electrolytes) and antibiotics (erythromycin). Mild cases may resolve without antibiotics. The disease in people is similar to that in monkeys. Severe diarrhea with abdominal cramps may occur. Shigellosis Shigella flexneri is a common cause of diarrhea in macaque monkeys. Although S. sonnei is the most common cause of shigellosis in man, cross infection is possible. Humans may also be the reservoir for monkey infections, 3 Last printed 5/14/2017 5:49:00 AM but asymptomatic carriers may maintain the infection in the colony between outbreaks. Shigella is very infectious and as few as 500 bacteria will causes infection. Children are more susceptible than adults. Outbreaks are more common in hot weather. Diarrhea with blood and mucous is the most common clinical sign. Shigellosis may be fatal in monkeys if untreated, but most animals respond rapidly to antibiotics and parenteral fluids. Affected monkeys should be isolated. The human disease is often mild in adults, but may be very debilitating or fatal in children. Other enteric bacteria and parasites Yersinia enterocolitica is more rare than the previously mentioned pathogens, but can also cause severe diarrhea and dehydration in people and monkeys. Salmonella is not common in nonhuman primates. Infection can occur from contact with an infected person or from consumption of contaminated food, especially poultry. Mild or severe diarrhea can occur. Escherichia coli occasionally causes diarrhea which may either watery or contain blood and mucous. Giardia lamblia, Cryptosporidium parvum, Enterocytozoan bieneusi, Balantridium coli, and Entameba histolytica are all intestinal protozoa that can infect monkeys and man. Diarrhea can range from mild to severe. These parasites are rare in most laboratory primates. Wild-caught monkeys occasionally harbor other parasites that can infect people. Blood borne parasites Wild-caught monkeys may carry several parasites in their blood. The animals may have very minor clinical signs. Casual contact or routine handling is safe, but needle stick injuries may be hazardous. Trypanosoma cruzi is a blood borne protozoan that causes Chagas’ disease. Chagas’ disease causes debilitation and cardiomyopathy in man. Many wild-caught squirrel monkeys carry this parasite. Malaria (Plasmodium spp) may also be present in wild caught monkeys. Tuberculosis Tuberculosis is a serious concern at all laboratory primate facilities. Tuberculosis is rare in wild monkeys but can readily be acquired from infected humans. All species can be affected. Our colony has been free of Mycobacterium tuberculosis for greater than 15 years but we remain vigilant due to the severity of disease following transmission of the bacteria from humans to animals. Tuberculosis causes severe weight loss, lethargy and coughing and is almost always fatal in monkeys, but the disease can go unrecognized for months during which time other animals may be infected. Strict quarantine of new animals and regular testing of the entire colony identifies asymptomatic monkeys. Infected animals are not treated. 4 Last printed 5/14/2017 5:49:00 AM People may have asymptomatic infections or may suffer severe respiratory disease and weight loss. Routine tuberculin testing detects most human cases. All individuals who work with monkeys, including visiting faculty and students, must have annual skin tests to show that they do not have tuberculosis. Individuals with positive skin tests must have an alternate evaluation such as a chest radiograph by a health professional before they may work with primates. Harvard Medical School staff and students may obtain tuberculin skin tests or radiographs at no charge from the University Health Services (432-1370). Individuals with other primary affiliations should be tested at their home institution. Written documentation of tuberculin skin test results must be presented to the ARCM Associate Director for Operations (Dr. D. Lee-Parritz) before requesting access to nonhuman primate facilities. Herpes B (Herpesvirus simiae) Herpes B virus infection of man is very rare but is often fatal. The Herpes B virus is present in about 25% of rhesus and cynomolgus monkeys; only 2-3% of these monkeys have clinical signs at a given time. Herpes B virus does not infect baboons, squirrel monkeys or owl monkeys. Infected animals may have conjunctivitis or ulcers or white plaques on the lips, nares, tongue, palate or genitalia. Diagnosis of Herpes B infection in monkeys is often difficult because infected animals may not have detectable antibody and shed virus only intermittently. For that reason, you must assume that all macaque monkeys are potential carriers of this virus. Infection of man may occur after bites, scratches, needle sticks, splashes to the eye or injuries caused by macaque caging. The incubation period of the disease in man is between 2 weeks and 6 months. Pain, numbness and weakness of the affected arm may occur, accompanied by generalized malaise and flu-like symptoms. Coma and death result from central nervous system infection. Due to the severe consequence of human B virus infection, all injuries caused by macaques or their caging must be taken seriously. In the event of an injury washing the wound for 15 minutes is the most important first step. The injured employee must report the injury to the supervisor and occupational health services for evaluation. Other viruses Herpes viruses are common in other primate species but are not hazardous to humans. In general, these viruses do not cause disease in their natural hosts but can be fatal to other primate species. In particular, Herpesvirus saimiri and Herpesvirus tamarinus cause no clinical disease in squirrel monkeys but are lethal in owl monkeys and marmosets. Human herpes viruses are highly pathogenic for owl monkeys and marmosets. Animal care workers should take care to avoid cross contamination of these species by the use of shared equipment and should not work with New World species when they have active cold sore lesions. 5 Last printed 5/14/2017 5:49:00 AM Measles Measles is rare in wild monkeys but unvaccinated monkeys acquire the disease readily from other monkeys or from infected people. Unvaccinated or improperly vaccinated people may contract the disease from monkeys during an outbreak. Improperly vaccinated people may introduce the infection into a primate colony. The incubation period in monkeys is usually 5-15 days. Affected animals develop conjunctivitis, lethargy, and a diffuse rash. Pneumonia, abortion, secondary bacterial infection and death can occur. New World monkeys are more susceptible to measles than are Old World monkeys. Our monkeys are protected by vaccination but we remain vigilant due to the severity of disease following transmission of the virus from humans to animals. Immunodeficiency viruses. Infection of monkeys with Simian Immunodeficiency Virus (SIV) causes an AIDS-like syndrome in macaques but only occurs in experimental infectious disease laboratories. There are no macaques infected with SIV at the Longwood campus. SIV is not known to be pathogenic to people, but it is closely related to human immunodeficiency virus (HIV) and the virus can infect human cells in tissue culture. Type D retrovirus is another immunosuppressive macaque retrovirus that can cause diarrhea, weight loss and recurrent infections. Macaques at the Longwood Medical Area are regularly screened for this virus to prevent inadvertent introduction of infected animals. D retrovirus is not infectious to people. Need more information? Please ask a member of the veterinary staff to explain any information in this pamphlet that is not clear to you. You may also speak with an occupational health professional if you have personal medical questions related to your work with laboratory animals. Please contact your supervisor if you require additional training or if adequate protective equipment is not available to you. Protective equipment and safety practices Purpose The purpose of this section is to describe safe work practices when handling laboratory primates. They are intended to protect employees working with macaques or macaque tissues from the risk of Herpes B virus infection and other infectious diseases. General Information Monkeys are wild animals and can cause serious physical injury or infection through bites, scratches, spitting, and passively by contact with contaminated fluids or tissues. A summary of known infectious agents that monkeys may transmit to people is contained in the previous section of this handout. 6 Last printed 5/14/2017 5:49:00 AM Monkeys may also harbor unknown or difficult-to-diagnose pathogens. For these reasons, you must always use good work practices and use personal protective equipment when working with nonhuman primates. Compliance No one may work with a monkey until he or she has received orientation and training in the measures described in this manual. Employees must wear work clothing and personal protective equipment and follow all work practices and safety measures described in this manual. Responsible Persons and Enforcement Procedures described in this manual are the personal responsibility of all personnel working with monkeys. These include the following employees: Principal Investigators, Research Technicians, Veterinarians, and Animal Care Technicians. Compliance with requirements for personal protective equipment shall be monitored and enforced by the facility manager, animal care supervisors, veterinarians and environmental health and safety officer. Noncompliant ARCM employees are the responsibility of the Associate Director for Animal Care and the Director of ARCM. Noncompliant research staff are the responsibility of the Principal Investigator and Department Chair. Individuals who repeatedly fail to follow required procedures are subject to progressive disciplinary action, which may include reassignment or termination. Work clothing and work shoes The employer will provide all necessary work clothes (scrubs, uniforms or lab coats) and personal protective equipment (PPE) to personnel working with monkeys. Animal care technicians working in animal rooms must wear work clothing and work shoes at all times. Research staff and veterinarians may wear laboratory coats over street clothes. Soiled work clothing and laboratory coats must be placed in suitably labeled hampers for laundering by the laundry service. Employees must not launder work clothing at home. Work shoes must be kept in a locker at the Center and should not be worn home. Personal protective equipment All staff must use supplementary PPE when working in nonhuman primate rooms or clinical procedure rooms, or when working with potentially contaminated cages, bedding, or equipment. Research staff must wear a mask whenever a nonhuman primate is present in a laboratory, however the use of eye protection is required only if the investigator is working within 1m (3 feet) of a nonhuman primate. Face (“surgical” or “comfort”) masks. 7 Last printed 5/14/2017 5:49:00 AM Eye protection, including brow and side guards. A face shield is required when washing cages or rooms. Sleeve protectors are required when feeding, scraping, changing water bottles or transferring macaques Gloves Employees with skin lesions such as dermatitis, abrasions and lacerations must consult with an occupational health professional before work to evaluate the potential need for additional personal protective equipment such as bioocclusive dressings or assignment to a different task. Personal Hygiene Frequent hand washing is the most important part of good personal hygiene. Employees must always wash their hands after working in the animal facility, especially before eating. It is recommended but not required that all employees working with animals shower at the end of the workday before changing into street clothing and street shoes. Training Employees will be trained at the time of hire in the following points: Safe work practices in animal care Herpes B virus risks and transmission Risks associated with working with monkeys Zoonosis training Standard operating procedures for personal protective equipment; how to put on, use and take off Limitations of personal protective equipment Injury reporting Continuing education on these points will occur annually and as needed to ensure employee compliance. Post exposure management of macaque bites and scratches Stop what you are doing. If you are working with an animal, secure it in the cage. Notify your supervisor. If you were bitten or scratched by a macaque, take precautions against Herpes 8 Last printed 5/14/2017 5:49:00 AM B infection. Supplies and additional information are in the B Virus Bite Kit that is in each animal room. You must do the following three things immediately: 1. Disinfect your wound. Wash the wound with the Betadine ® scrub brush and water for 15 minutes. If there is no Betadine ® scrub brush, wash with any hand soap or detergent for 15 minutes. For an eye splash, go to closest eye wash station and rinse the affected eye for 15 minutes or until container is empty. 2. See an occupational health professional. Call the University Health Services clinic (432-1370). If you are a Brigham and Women’s Hospital employee, call BWH Occupational Health (7326034). Tell them that you have been bitten or scratched by a macaque and that you must be seen immediately. If the UHS or BWH Occupational Health Clinics are closed, call the Brigham and Women’s Hospital emergency department (732-5636). Bring the packet of printed materials in the bite kit with you to the clinic. 3. Have the animal evaluated for possible Herpes B infection. Samples must be collected the same day as the injury. Call the ARCM main number (432-1285) and ask the veterinary staff to evaluate the primate, and collect serum and culture samples. On weekends and holidays, page the on-call veterinarian. The emergency schedule and contact information is posted in each animal facility. If you were bitten or scratched by any other primate, you should disinfect your wound and see an occupational health professional as described in steps 1 and 2. It is not necessary to evaluate species other than macaques for possible Herpes B infection. Examination and culturing of nonhuman primate As soon as possible following the exposure, the ARCM veterinary staff will tranquilize and examine the primate. Call the ARCM main number (432-1285) and ask the veterinary staff to evaluate the primate, and collect serum and culture samples. On weekends and holidays, page the on-call veterinarian. The emergency schedule and contact information is posted in each animal facility. The examination will include observation of the oral cavity, conjunctiva, and genitalia. If ulcers, vesicles or erosions are present, the veterinarian will notify the occupational health professional. All exposures from animals with suspect lesions will be considered “high risk.” The veterinary staff will collect serum for Herpes B antibody determination as well as viral cultures from all macaques that bite or scratch. Cultures will be obtained from the oral cavity, conjunctiva and any suspect lesions. Specimens for viral culture will be obtained using approved viral transport swabs. Serum samples and cultures will be sent to the NIH N Virus Resource Laboratory (University of Georgia, telephone 404-651-0808) for analysis. Cultures must be shipped overnight express on dry ice and the lab must be called to expect the shipment. Serum samples may accompany the cultures, or may be sent separately with “blue ice” packs. A 2 ml serum aliquot will be retained at 9 Last printed 5/14/2017 5:49:00 AM ARCM, frozen at -20oC. The serum antibody check will be repeated two weeks after the injury. Injuries on nights and weekends If an exposure occurs on a weekend or holiday, the Brigham and Women’s Hospital emergency department will provide emergency care of the employee. The on-call veterinarian must be called to evaluate and collect samples from the primate. Cultures may be safely frozen at -20oC for 48 hours prior to shipment to the Herpes Virus Reference Laboratory. The veterinary call schedule is posted in each animal area. A directory of veterinary staff office and pager numbers is also included in this directory. Postexposure monitoring Results of the monkey’s B virus culture will be reported to the occupational health professional who will inform the employee of the results. Should the culture be positive or indeterminate or if the employee experiences symptoms of possible B virus infection, the employee will be immediately referred to an infectious diseases specialist for further treatment. A positive antibody test on a previously seronegative animal with a negative culture may also require additional treatment or antiviral drug treatment according to the physician’s evaluation. An accident report will be processed with a copy filed with the ARCM Associate Director for Operations (David Lee-Parritz DVM). An occupational health professional will monitor the individual weekly for three weeks after the injury. These visits will be documented in the individual’s medical record. If the primate’s culture and antibody test is negative and the employee remains asymptomatic, no other medical treatment will be necessary. Directory for Medical Care of Monkey Bites and Scratches Harvard Medical Area (Monday – Friday, 9 AM – 4 PM) University Health Services (Peter Massicott, MD) 275 Longwood Avenue, Boston MA 02115 (617) 432-1370 Brigham and Women’s Hospital Occupational Heath Services (Monday – Friday, 7:30 AM – 4:30 PM) (617) 732-6034 or (617) 732-8501 Nights, Weekends, Holidays Brigham and Women’s Hospital Emergency Room (617) 732-5636 10 Last printed 5/14/2017 5:49:00 AM Infectious Disease Consultant R. Paul Johnson, MD. 508/624-8148 (office - NERPRC) 617/726-3812 (office - MGH) 617/726-5772(lab) 617/726-7777 (Beeper 32519) ARCM Veterinary Staff David Lee-Parritz DVM (617) 432-2162 (office) Angie Warner DVM (617) 432-0888 (office) (617) 236-9203 (pager) (617) 236-9196 (pager) NIH B Virus Resource Laboratory Viral Immunology Center Georgia State University 50 Decatur Street Atlanta, GA 30303 (404) 651-0808 (404) 651-0814 (fax) http://www.gsu.edu/~wwwvir/index/html References 1. Bennett B.T., Abee C.R., Henrickson R. Nonhuman Primates in Biomedical Research: Diseases. Academic Press 1998. pp 1:1-48, 2:59-102, 3:111-179. 2. Brack M. Agents Transmissible from Simians to Man. Springer-Verlag Berlin Heidelberg 1987. 3. Holmes G.P., Chapman L.E., Stewart J.A., et al. Guidelines for the Prevention and Treatment of B-Virus Infections in Exposed Persons. In: Clinical Infectious Diseases 1995; 20:421-39. What to do if you are injured Stop what you are doing. If you are working with an animal, secure it in the cage. Notify your supervisor. If you were bitten or scratched by a macaque, take precautions against Herpes B infection. Supplies and additional information are in the B Virus Bite Kit that is in each animal room. You must do the following three things immediately: 4. Disinfect your wound. Wash the wound with the Betadine ® scrub brush and water for 15 minutes. If there is no Betadine ® scrub brush, wash with any hand soap or detergent for 15 minutes. For an eye splash, go to closest eye wash station and rinse the affected eye for 15 minutes or until container is empty. 5. See an occupational health professional. Call the University Health Services clinic (432-1370). If you are a Brigham and Women’s Hospital employee, call BWH Occupational Health (7326034). Tell them that you have been bitten or scratched by a macaque and that you must be seen immediately. If the UHS or BWH Occupational Health Clinics are closed, call the Brigham 11 Last printed 5/14/2017 5:49:00 AM and Women’s Hospital emergency department (732-5636). Bring the packet of printed materials in the bite kit with you to the clinic. 6. Have the animal evaluated for possible Herpes B infection. Samples must be collected the same day as the injury. Call the ARCM main number (432-1285) and ask the veterinary staff to evaluate the primate, and collect serum and culture samples. On weekends and holidays, page the on-call veterinarian. The emergency schedule and contact information is posted in each animal facility. If you were bitten or scratched by any other primate, you should disinfect your wound and see an occupational health professional as described in steps 1 and 2. It is not necessary to evaluate species other than macaques for possible Herpes B infection. 12 Last printed 5/14/2017 5:49:00 AM