Download SERIOUS RISK OF HERPES B-VIRUS EXPOSURE EXPOSURE

IN THE EVENT OF AN EXPOSURE YOU MUST TAKE THIS PACKET
WITH YOU TO THE EMERGENCY DEPARTMENT
ATTENTION PHYSICIANS!
You must read the following information!
SERIOUS RISK OF HERPES B-VIRUS EXPOSURE
NOT HEPATITIS B VIRUS
You must read the following information!
Cheryl S. Barbanel, MD, MBA, MPH, FACOEM
Director, Occupational Health Programs at Boston University
Revised 4/17/07
2
This document (web page or PDF file) is the current guidelines for managing B virus
exposure. These recommendations are reflected in the documents in this packet.
Web Page: Recommendations for Prevention of and Therapy for Exposure to B Virus
PDF File:
CID Reference.pdf
Table of Contents
Page
Macaque Monkeys: Description & Photos ............................................................ 3
BMC Emergency Medicine Clinical Practice Guidelines Algorithm .................... 5
Initial Management by Healthcare Provider (Overview) ....................................... 6
Instructions for Clinic and Emergency Department Staff .................................... 8
Evaluation of Post Exposure Prophylaxis for B Virus Exposure ........................ 9
Treatment of B Virus Infection ...............................................................................11
Occupational Health Follow-up Clinic Visits.........................................................12
Report of Injury Involving a Nonhuman Primate Body Fluids .............................14
Macaque Monkey Program: Possible Infectious Agents & Their Control ..........18
Rules To Prevent B Virus Infection in Primate Handlers .....................................19
Infectious Hazards from Nonhuman Primates Table............................................21
B Virus Exposure Mini Protocol .............................................................................22
B Virus Sample Collection & Handling ..................................................................24
B Virus Submission Form.......................................................................................26
Employee Bite and Scratch Log.............................................................................27
Boston Public Health Reporting Requirements....................................................30
3
Macaque Monkeys
Macaques live in many different habitats across the globe, making them the most widely distributed
genus of nonhuman primates. Macaques (especially Macaca mulatta and M. fascicularis) are
commonly used in research—most recently in AIDS research. Their coloration includes gray, brown
or black fur. They tend to be heavily built and medium to large in stature. Males and females may
differ in weight, body size and canine size. (from Nonhuman Primates in Biomedical Research:
Biology and Management pp 41)
Macaques are native to Asia and Northern Africa, but thousands are housed in research facilities,
zoos, wildlife or amusement parks, and are kept as pets in private homes throughout the world.
Pictures of Macaque Monkeys (alphabetical order)
Assamese macaque
(Macaca assamensis)
Assamese macaque
(Macaca assamensis)
Barbary Macaque
( Barbary "ape" or
Barbary Macaque )
Barbary Macaque
(Macaca sylvanus)
Bonnet Macaque
(Macaca radiata)
Bonnet Macaque
(Macaca radiata)
Booted or SulawesiBooted Macaque
(Macaca ochreata)
Celebes "ape", Sulawesi
Black "ape", or SulawesiCrested Macaque
(Macaca Nigra)
4
Formosan Rock Macaque
or Taiwan Macaque
(Macaca cyclopis)
Japanese Snow Macaque
(Macaca Fuscata)
Japanese Macaque
(Macaca Fuscata)
Japanese Macaque
(Macaca Fuscata)
Lion-tailed Macaque
(Macaca silenus)
Cynomolgus monkey, CrabEating Macaque, LongTailed Macaque, or Java
Macaque
(Macaca fascicularis)
Pigtailed Macaque
(Macaca nemestrina)
Rhesus Macaque
(Macaca mulatta)
Tibetan Macaque
(Macaca thibetana)
Tonkean Macaque
(Macaca tonkeana)
Tonkean Macaque
(Macaca tonkeana)
Toque Macaque
(Macaca sinica)
5
BMC Emergency Medicine
Clinical Practice Guideline
SIMIAN HERPES B
VIRUS EXPOSURE
This guideline is to be used to assist in clinical efficiency, but is
not a substitute for clinical
judgment
PRIMATE EXPOSURE
- POSSIBLE SIMIAN
HERPES B VIRUS
EXPOSURE
Monday – Friday
Non-Holiday
7:30 am – 4:00 pm
Herpes B Virus Prophylaxis
Recommended
1. Skin exposure or mucosal exposure (with
or without injury, i.e. eye) to a high-risk
source
2. Inadequately cleaned skin exposure or
mucosal exposure
3. Laceration of head, neck, or torso.
4. Deep puncture bite
5. Needlestick associated with tissue or
fluid from the nervous system, lesions
suspicious for B virus, eyelids, or mucosa
6. Puncture or laceration after exposure to
objects (a) contaminated either fluid from
monkey oral or genital lesions or with
nervous system tissues, or (b) known to
contain B virus.
7. A post cleaning culture is positive for B
virus
Herpes B Virus Prophylaxis Considered
1. Mucosal splash that has been adequately
cleaned
2. Laceration (with loss of skin integrity)
that has been adequately cleaned
3. Needlestick involving blood from an ill or
immunocomprimised macaque
Puncture or laceration occurring after
exposure to (a) objects contaminated with
body fluid (other than that from a lesion), or
(b) potentially infected cell culture
SIMIAN HERPES B VIRUS (Cercopithecine herpes virus 1)
• Endemic in Macaque Monkeys (rhesus. Pig-tailed, bonnet, cynomolgus)
ALL MACAQUES MUST BE ASSUMED TO BE VIRUS +
• 70% case fatality rate when transmitted to humans
•
Transmitted through open skin and mucocutaneous exposures (bites,
scratches, needlesticks, splashes over mucus membranes, open skin)
•
Biomedical lab workers, animal handlers at risk (live monkeys, monkey
tissue cultures, body fluid exposures – blood, secretions, excretions)
•
2days – 5weeks incubation period, but latent presentations occur
•
Disease In Humans: Early-Skin vesicular eruptions, ulcerations; regional
nodes; Late – Fever, malaise, diffuse pain, HA, abd pain, n/v, parasthesias,
encephalitis, paralysis, death
• Exposures include macaque bites, macaque scratches, or contact with ocular, oral, or
genital secretions, nervous system tissue, or material contaminated by macaques.
REFER TO OCCUPATIONAL
& ENVIRONMENTAL
MEDICINE
YES
BPHC Lab reporting regulations applies to B
Virus. Report exposures, illnesses, or
absenteeism to Occupational Health Officer
at (617) 353-6630 or (617) 780-5519 (cell) or
OEM. Complete the BPHC Research
Laboratory Reporting Form found at:
http://www.bphc.org/bphc/pdfs/LabReportCa
rd.pdf
1. Wound care – cleanse &
irrigate with detergent for 15
minutes; debride only if necessary.
2. Eye flush/irrigation for 15 min.
3. Valacyclovir, 1 g po q8h for 14
days*
4. Culture – debrided tissue
should be placed in viral transport
media and sent for B-virus cx;
swab wound for viral cx as well.
5. Start Abx – Augmentin or
Keflex for bites.
6. Td as indicated (booster if bite
and Td > 5 yrs ago)
7. Acute serum collection (aliquot
and preserve at –20ºC or lower and
send to micro lab, complete forms
for B virus lab.
8. Provide patient information in
first aid packet and schedule OEM
follow-up appointment.
Herpes B Prophylaxis Not Recommended
1. Skin exposure in which the skin remains
intact
2. Exposure associated with non-macaque
species of nonhuman primates
TO BE INTERVIEWED
IMMEDIATELY
BMC OEM
732 HARRISON AVE
BOSTON, MA 02118
(617) 638-8400
NO
Refer to Boston Medical
Center
EMERGENCY
DEPARTMENT
MENINO PAVILION
(617) 414-7759
Patients Must Be Evaluated
at
OCCUPATIONAL &
ENVIRONMENTAL
MEDICINE
Next Business Day
732 Harrison Avenue
Boston, MA 02118
(617) 638-8400
ANY PATIENT
PRESENTING WITH
SYMPTOMS OF B VIRUS
SHOULD BE ADMITTED
FOR IV GANCICLOVIR
CONSULT ID SERVICE
EMERGENCY CONSULTATION
If an exposed person exhibits any of these
symptoms please contact Julia Hilliard, Ph.D. at
the National B Virus Resource Center at
404.651.0808
http://www.gsu.edu/bvirus
*Valacyclovir substitute: Acyclovir, 800 mg po 5 times per day for 14 days if pregnant
6
INITIAL MANAGEMENT OF B VIRUS EXPOSURE BY HEALTHCARE
PROVIDER:
Obtain current contact information for patient including cell phone or other phone contact.
First Aid
Employee performs first aid as within 5 minutes of injury as defined below which is repeated
by clinician.
Mucous membrane exposure
Flush eye or mucous membranes with sterile saline solution or water for 15 min.
Skin exposure
Wash skin thoroughly with a solution containing detergent soap (e.g., chlorhexidine or
povidone-iodine) for 15 min
Initial Evaluation
Human
Assess the adequacy of cleansing (length of time of cleaning and agent used); the health care
provider should repeat cleansing as above regardless of history of cleaning
Determine the date, time, location, and description of the injury, and the type of fluid or tissue
contacted, safety procedures and PPE used
Evaluate general health (including medications) and determine when the last tetanus booster
was received
Determine the need for post-exposure prophylaxis with antibiotics or rabies vaccine and
immunoglobulin (Rabies are not usually an issue with NHP that are not in quarantine)
Nonhuman primate
Identify the monkey associated with the exposure, the species of that monkey, and the
responsible veterinarian should be contacted regarding the health status of the monkey
involved
Assess general health (including medications and involvement in past and present research
studies)
7
Evaluate prior serologic history (including infection with B virus or simian immunodeficiency
virus)
Examination and Laboratory Testing
Human
Physical examination, especially evaluation of the site of the exposure and neurologic
examination
Examine the area that has been exposed carefully for evidence that an exposure has occurred
Consider obtaining serum samples at baseline for serologic analysis
Consider culturing specimens from the site of the wound or the exposed mucosa
Do not culture wound before cleaning. This is contraindicated as it may further
contaminate the wound.
Nonhuman primate
Examine the animal for mucosal lesions (e.g., vesicles, ulcers), conjunctivitis, etc.
Consider culturing specimens from the lesions, conjunctiva, and buccal mucosa
Consider serologic testing for B virus (if the animal is not known to be seropositive)
Education and Treatment
Counsel the patient regarding the significance of the injury
Ensure that the patient's occupational health care provider and supervisor are notified of injury
Review with the patient and his or her work supervisor the safety precautions in place at the
time of injury
Schedule a follow-up appointment
Determine if tetanus or prophylactic treatment with antibiotics is indicated
Consider postexposure prophylaxis for B virus below
Patient Education and Follow-up is included in the first aid information pack: Provide the
patient with all the information in the package that has First Aid on the cover.
8
1.
Review information on the signs and symptoms of B virus infection in packet.
2.
Ensure that the patient has a card (to carry in his or her wallet) that includes information
on B virus and a phone number to call for advice in an emergency.
3.
Patients should be counseled regarding transmission of B virus to others after an
exposure by body fluids or skin lesion contact.
4.
Provide the patient with information on B virus symptoms, emergency contact card with
B virus emergency contact information, and referral to Occupational Health on the next
business day, tel: (617) 638-8400, (If seen in the Emergency Department).
INSTRUCTIONS FOR CLINIC AND EMERGENCY DEPARTMENT STAFF
Bite, Scratch, Mucous Membrane Exposure or Contaminated Needle Stick,
Scalpel or Cage Injury
Assess the adequacy of wound cleansing and repeat 15 minutes more of cleansing as
described in previous section.
Splash to the eye: This should rarely occur because employees should be wearing face
shields and safety glasses with side shields, or goggles with a surgical mask. If the employee
is exposed to contaminated secretions, then, following the immediate cleansing of the eye for
15 minutes, a culture from the eye and serology studies should be done as outlined above.
Repeat 15 more minutes of eye wash in ED or Clinic
Evaluate the need for debridement and prophylactic antibiotics, e.g., Augmentin (drug of
choice) or cephalosporin, to prevent bacterial infection.
Collect a viral culture from the wound or exposure site after washing and disinfecting. (Use
Viral Transport Media and sterile cotton or polyester "Dacron" swabs.)
Collect baseline blood specimen for antibody titers to B virus. (The paired serum will be
collected at three weeks from exposure at the BMC Occupational & Environmental Medicine
Clinic, on F5, phone (617) 638-8400.
Document adequacy of wound cleaning, record mechanism of injury, likelihood of wound
contamination, effectiveness of wound cleaning, tetanus status, and general evaluation of
patient’s health (medication use, allergy to medications and baseline medical conditions).
Document examination of wound and overall physical examination sufficient to provide
comparison if patient condition changes (dermatologic, ocular, respiratory, cardiovascular,
lymph nodes, and neurologic examinations.
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Counsel the patient on symptoms to watch for and precautions to take at home while
awaiting results of cultures and blood tests. (Normally, viral cultures are reported as
negative in one week and serology results should be reported in two to three weeks. Until then
the CDC guidelines recommend that, "It is prudent for persons who have had high-risk
exposures to avoid activities involving the exchange of body fluids (including saliva) until
tests of sera have shown no evidence of seroconversion."
Ensure proper storage of specimens prior to shipment. (If held longer than two hours, viral
serum specimens should be frozen. See Sample Collection and Handling Forms Below.)
Notify the Microbiology Laboratory at East Newton Campus 617-638-7890 and tube the
specimens to pneumatic tube station #2. Make sure the correct B Virus forms are filled out.
Initial serum specimen needs to be frozen as instructed on form and sent out with paired
specimen two weeks later.
Virology and blood samples from the involved monkey will be the responsibility of the company
veterinarian.
Refer the patient to follow-up on next business day to BMC Occupational and Environmental
Medicine, tel: 617-638-8400.
Provide the patient with Dr. Hilliard’s (NIH B-virus laboratory) tel: (404-651-0808).
Emergency: Dr. Julia Hilliard, Director: 404-358-8168 for emergency and a list of symptoms
of concern below (in packet labeled first aid).
Notify attending veterinarian. To date all macaque monkeys that have been tested have been
positive serologically for B-virus. Leave message at 617-638-4086.
All information necessary to provide to exposed employee is prepared for the employee in the
Employee First Aid Postexposure Prophylaxis Instructions for B Virus and Employee Training
Packet.
EVALUATION OF POST EXPOSURE PROPHYLAXIS FOR B VIRUS EXPOSURE
Exposures Include: macaque bites; macaque scratches; or contact with ocular, oral, or
genital secretions, nervous system tissue, or material contaminated by macaques (e.g., cages
or equipment) (see the Postexposure Prophylaxis section of the text for details).
Prophylaxis Recommended
___ Skin exposure (with loss of skin integrity) from a high-risk source
___ Mucosal exposure (with or without injury) from a high-risk source (e.g., a
macaque that is ill, immunocompromised, or known to be shedding virus or that has
lesions compatible with B virus disease).
___ Inadequately cleaned skin exposure (with loss of skin integrity) or mucosal
exposure (with or without injury)
___ Laceration of the head, neck, or torso
___ Deep puncture bite
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___ 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
___ A postcleansing culture is positive for B virus
Prophylaxis Considered
___ Mucosal splash that has been adequately cleaned
___ Laceration (with loss of skin integrity) that has been adequately cleaned
___ Needlestick involving blood from an ill or immunocompromised macaque
___ Puncture or laceration occurring after exposure to (a) objects contaminated
with body fluid (other than that from a lesion), or (b) potentially infected cell culture
Prophylaxis Not Recommended
The only situations that prophylaxis is not recommended is those exposures in which the skin
remains intact, or exposures associated with non-macaque species of nonhuman
primates.
PROPHYLAXIS for exposure to B virus (See PDR for specific prescribing information)
Drug of first choice: Valacyclovir, 1 g po q8h for 14 days;
Alternative drug: Acyclovir 800 mg po 5 times per day for 14 days (consider if pregnant
as drug of choice)
Draw initial serum at time of injury and convalescent serum at 2 weeks and 4
weeks after discontinuation of prophylaxis or if there are any symptoms of B
virus in those potentially exposed at anytime.
11
B Virus Symptoms
Inform patient to contact clinic immediately or emergency department at BMC if any
symptoms potentially related to B-Virus occur. Remind employee to continue to be
aware of these symptoms for the next several weeks. (See below)
Symptoms that Could Be Related to a B Virus Infection
For an employee who reports symptoms that could be related to a B virus infection, the
protocol depends upon the exposure history. If the worker gives no history of exposure
and the signs or symptoms are not specific to a herpesvirus infection, e.g., a flu-like
illness, then the physician should consider simply observing the patient. Further
assurance could be obtained by drawing blood for serology studies. Check with the B
Virus Laboratory to see if they recommend doing studies on a "stat" basis.
If the risk of infection appears to be higher, either because of the history of a recent
exposure or because of symptoms specific for a B virus infection, then hospitalization
and intravenous antiviral therapy should be considered. When setting up the prevention
program, a local hospital-based physician, knowledgeable in the treatment of B virus,
should be designated as the consultant for the clinic.
For consultation by phone: 404.651.0808
Emergency: Dr. Julia Hilliard, Director of the NIH B Virus Lab: 404.358-8168
Clinical manifestations suggesting active infection with B virus.
Early manifestations (inconsistently present)
1. Vesicular eruptions or ulcerations at or near the exposure site
2. Severe pain or itching at the exposure site
3. Regional lymphadenopathy
Intermediate manifestations (inconsistently present)
1. Fever
2. Numbness, paresthesia, or other neuresthesias at or near the exposure site, with or without
proximal progression.
3. Muscle weakness or paralysis in the exposed extremity
4. Conjunctivitis
5. Persistent hiccups
Late manifestations (avoidable with early therapy)
1. Sinusitis
2. Neck stiffness
3. Headache lasting > 24 hours
4. Nausea and vomiting
5. Brain-stem findings: diplopia, dysarthria, dysphagia, dizziness, cross hemiparesis,
cerebellar signs with ataxia, crossed sensory loss, cranial nerve palsies, or drop attacks
6. Altered mentation
7. Other signs compatible with CNS impairment or viral encephalitis including urinary
retention, respiratory failure, convulsions, twitching, hemiparesis, hemiplegia, other
localized neurological signs, progressive ascending paralysis, or coma
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TREATMENT OF B-VIRUS INFECTION
Standard precautions: Should be used in taking care of patients undergoing treatment for B
virus.
Any signs or symptoms of B virus disease or positive culture (not post-cleansing culture) start
treatment:
•
•
Contact ID attending and Contact B-virus Laboratory (404.651.0808)
Take detailed history and physical examination, documenting skin lesions and
neurological status.
Laboratory Studies:
•
•
Culture lesions, conjunctiva, oropharynx, for B virus, serological testing for B virus
using appropriate Viral Transport Media and cotton or dacron swabs.
CBC with differential, pregnancy test, Lumbar puncture, MRI of the brain, EEG to
differentiate herpes simplex viral encephalitis, consider brain stem auditory evoked
potential
Treatment:
Most experts believe that therapy should be switched to oral valacyclovir, famciclovir, or
acyclovir at the dosage used for post-exposure prophylaxis. Repeated cultures of the
conjunctivae and oral mucosa weekly during the first few weeks of discontinuation of therapy is
recommended. If neurological symptoms develop at any time, cultures for B virus should be
obtained.
OCCUPATIONAL HEALTH FOLLOW-UP CLINIC VISITS FOR B-VIRUS EXPOSURES
Include patient name, date and time of visit. Date of initial exposure. Week since initial
exposure. Contact information including cell phone, work phone, home phone. ID#,
immediate supervisor and supervisor phone number.
You must contact any patient that misses a B-virus F/U appointment.
13
Week 1 Follow-up visit in OEM:
1) Make sure serum was sent to the BMC microbiology lab.
2) If baseline serum not drawn get baseline serum and send to BMC microbiology lab to send
out with paired specimen to be drawn end of week 2 or beginning of week 3. Only paired
serum will be sent to B virus laboratory. See information on collection of cultures and
serum in this packet.
3) If employee was seen in the Emergency Department get record.
4) Review need for prophylactic antibiotics, and tetanus booster. [After a bite, booster
should be given if the last tetanus is greater than 5 years ago].
5) Review decision for antiviral prophylaxis for B virus. Exposure and prophylaxis]. (See p.
9-10)
6) Contact vet regarding health status of NHP.
7) Evaluate wound if a bite. (Look for vesicles or redness, swelling, or other signs of infection.
8) Evaluate patient for symptoms of B virus using the checklist below. Evaluate for skin
lesions or mucous membrane lesions at site of injury/bite consistent with herpetic lesions.
9) Perform serological testing if there is a change in clinical status.
10) Assess compliance with treatment if prophylaxis has been prescribed at each visit.
Any symptoms consistent with B virus contact physician in charge, Infectious disease
attending on call and B virus laboratory (emergency number after hours. See below for
initial instructions for evaluating and treating B virus disease.
11) Provide patient with information on B virus in (First Aid, Postexposure Prophylaxis and
training document.
12) Provide patient with a Medical Alert Wallet Card to carry, if not provided in ED.
Serological Testing
1) On day of exposure confirm or draw a baseline serum
2) Follow-up serum on week 2or 3 for all exposures from date of exposure.
3) If on PEP follow-up with patient weekly in person. Perform Serologic testing at week 2 or 3,
and 4 weeks after cessation of prophylaxis medication (about week 6) and at 12 weeks if
there are any concerns as to the exposed individual’s health status.
4) Serologic testing should be performed anytime there is a change in clinical status and 4
weeks after discontinuing prophylaxis for those on PEP. This also applies to patients
not on prophylaxis and present with symptoms. Anyone who presents with possible
symptoms and has potential for exposure needs additional evaluation by a physician and
the provider should consult with B virus laboratory.
Additional Follow-up
Include repeat steps 6 – 11, and Serologic testing if indicated as outlined above.
14
REPORT OF INJURY INVOLVING A NONHUMAN PRIMATE BODY FLUIDS
EMPLOYEE
AFFILIATION:
STUDENT
BUSM
OTHER
GSDM
OTHER
Name: ___________________________________________________________________________
SS#: _________________________Work Location: _______________________________________
ID: _____________________________
Occupation: ______________________________________________________________________
Tel: __________________________ Supervisor:_________________________________________
HISTORY
Date of Report: ___________________________ Time of Report: ___________________________
Date of Injury: ____________________________ Time of Injury: ____________________________
Location of Injury (Bldg., Floor, Room): _________________________________________________
Safety Measures Employed at Time of Exposure/Injury
________ Gloves, Specify type: _______________________________________________________
________ Sleeves
________ Eye Protection, Specify type: ________________________________________________
________ Mask, Specify type:
________ Other, Specify type:
Type of Exposure
________ Skin Exposure
Skin Integrity Broken: ________ Yes ________ No
________ Mucous Membrane Exposure
________ Eye(s), Specify: ________ R ________ L ________ Both
________ Nose
________ Mouth
________ Percutaneous Injury
________ Bite
________ Scratch
________ Eye(s)
Equipment involved: ______________________________________________
________ Puncture
________ Laceration, Depth ________ ________ Length
________ Instrument Involved _______________________________________________
If needle, gauge___________________ Hollow bore_____________________
15
Type of NHP Fluid Involved
________ Saliva (Consider BV – See source labs below)
________ Blood (Consider SIV, SRV)
________ Other, specify: ___________________________________________________________
Circumstances of injury (Include how the injury occurred and the body area involved):
__________________________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
First Aid at the Work Site
________ Wound cleansed/irrigated
Time elapsed from injury to initiation of first aid at the worksite
_____________________________
Agent(s) utilized: ________________________________________________________
Duration ______________________________________________________________
Other, specify: __________________________________________________________
EMPLOYEE’S LAB STUDIES (Check if Ordered)
________ Store Serum
________ Ocular BV Culture
________ Post-scrub
________ Other, explain:
___________________
__________________
TREATMENT (Check appropriate response(s)). For indications of post-exposure prophylaxis
refer to pages 9-10. If patient is potentially pregnant get a pregnancy test.
________ None Indicated
________ TD Update
________ Augmentin
________ Antiviral Med. _____________________________________________ Dose _________
Time lapsed from the time of injury to initiation of antiviral (B Virus) prophylaxis
________ Other, specify: ___________________________________________________________
________ Employee declines antiviral medicine offered
________ Decision held pending results of source’s and/or employee’s lab studies
INFORMATION PROVIDED (Check Appropriate Response(s)
________ B Virus Information Sheet
________ Other, describe:
__________________________________________________________________________________________
__ _______________________________________________________________________________________
16
FOLLOW-UP
________None indicated
________Follow-up serum (convalescent serums) 2 or 3 weeks (14-21days from date of injury), and 6
weeks *additional convalescent serum indicated if exposed was on antiviral medication, or
presents with symptom potentially consistent with B Virus.
Dates:
________ 1 week f/u
________ 2 week f/u, and send paired serums or on week 3
________ 3 week f/u
________ 4 week f/u
________ 6 week f/u or 1 month after cessation of PEP and send serum to B virus laboratory for
second convalescent titer.
________ 6* week f/u send second convalescent titer if any concerns about exposed persons
health status, not on prophylaxis
________ 12* week f/u if indicated as above.
EH&S NOTIFICATION
________Environmental Health & Safety Notified
Name:
Date and Time:
SOURCE (Consult Veterinarian at Laboratory Animal Science Center 617-638-4086)
Monkey identification: ______________________________________________________________
Veterinarian
Work Address ____________________________________________________________________
Species (Check One)
________ Rhesus
________ Cynomolgus
________ Other, specify: ___________________________________________________________________
Known illness(es) ______________________________________________________________
Clinical Evidence for Possible Current Herpetic Infection (e.g. mucosal ulceration, crusting,
conjunctivitis, etc.)
________ No
________ Yes, explain: ____________________________________________________________________
Existing Serologic Testing for B Virus
Result
________ Negative
________ Blood
________ Not Done
________ Not Available
Test Date
Testing Facility
________________________
______________________________
____________________
17
NHP’s LAB STUDIES (Check if ordered)
Result
Date Ordered
Date Received
________ Blood
________
____________________
____________________
________ Ocular BV Culture
_______
_________________
_________________
_______
_________________
_________________
________ Other Area Cultured
________ Buccal BV Culture
_______
_________________
_________________
Explain: ____________________________________________________________
________ Serum Anti-BV
_______
_________________
_________________
Nurse or NP _____________________________________________________________________________
Consulting MD: ________________________________________________________________
18
Questions for callers reporting an injury involving a nonhuman primate (NHP). Please note
that the risk for exposure to B Virus depends upon both the type of NHP and the body fluid
involved in the injury.
What type of NHP was involved in the injury?
NHP
CONSIDER
Old world monkeys
(e.g. rhesus, cynomolgus (cynos), bonnet, and stump tail)
B Virus
African green monkey, baboon, sooty mangabey, chimpanzee
SIV, (RESP)
Rhesus, cynomolgus, squirrel monkey, langur
SIV, (RESP)
Which NHP body fluid or tissue was involved in the injury?
NHP FLUID OR TISSUE
CONSIDER
Saliva, ocular or genital fluid, neurologic tissue, CSF
B Virus
Unknown (e.g. NHP scratch, cage related scratch)
B Virus
Blood or bloody fluids
SIV, SRV (RESP)
Urine, non-bloody fluids not mentioned above)
Neither B Virus nor SIV, SRV
In what type of research activities was the NHP involved?
Does that constitute a health risk for the injured worker?
First aid related questions.
What cleaning agent did you use
How did you use it?
How long did you use it?
MUCOUS MEMBRANE
SKIN
Saline or water
Irrigate
15 minutes
Betadine or Clinidine
Scrub
15 minutes
What was your last tetanus booster dose?
MORE THAN 10 YEARS
MORE THAN 5 YEARS
Repeat now
Repeat now for bite, avulsion
and crush injuries, and
injuries contaminated with
dirt or feces
Signature: _______________________________________________________________________________
Print Name: ___________________________________________________________________
19
MACAQUE MONKEY PROGRAM:
POSSIBLE INFECTIOUS AGENTS AND THEIR CONTROL
AGENT
WORKERS AT RISK
METHOD OF CONTROL
COMMENTS
B Virus
Macaque handlers,
cage cleaners and
necropsy technicians
See Rules to prevent infection below.
Source: macaque monkeys
shedding B virus (similar to
shedding of herpes simplex virus
by humans); Route: esp. through
bite or scratch; infection through
intact mouth or eye mucosa is
possible;
Tuberculosis
Macaque handlers and
others who work in
macaque rooms
TB skin test every 6-12 months to detect converters;
all new employees should have the two step test as
recommended by the CDC;
The monkeys are susceptible to
TB. Once introduced by a
human, the disease can spread
quickly through the colony.
Measles
Macaque handlers and
others who work in
macaque rooms
If born after 1/1/57, then a booster (MMR) is
recommended;
This is just a routine
immunization practice.
Hepatitis A
Macaque handlers and Personal protective equipment; good hand washing;
others exposed to fecal offer hepatitis A vaccine;
contamination
Hepatitis A vaccine is now a
routine immunization for
travelers to parts of the world
where hepatitis A is endemic.
Hepatitis B
Macaque handlers
Worker training regarding sharps; offer hepatitis B
vaccine;
Hepatitis B is now a routine part
of childhood immunizations. It is
also recommended to health care
workers who have exposures to
patients’ blood.
Tetanus
Macaque handlers
Booster every 10 years or give after tetanus prone
wound sustained if more than 5 years;
This is just a routine
immunization practice.
Prevention of bites by using safe handling methods;
consider treatment with Augmentin after deep bites;
Also consider debridement of
any contused and nonviable
tissue in the wound.
Bite wound infection Macaque handlers
Rabies
Macaque handlers
Observe animal after bite; if becomes ill, then consider It is unlikely that these
testing for rabies and beginning immunization of
previously quarantined primates
worker;
would contract rabies.
20
RULES TO PREVENT B VIRUS INFECTION IN PRIMATE HANDLERS
1. Know the safe methods for handling monkeys and sharps to prevent injuries.
2. Cleanse wounds thoroughly and without delay.
3. Collect specimens from both worker and monkey after an injury and ship promptly to the
NIH B Virus Resource Laboratory.
4. Report all injuries and know the symptoms of B virus infection. The evidence from
previous human infections suggests that patients survive if they are treated early before
advanced symptoms develop.
5. Provide post-exposure prophylaxis if indicated.
21
INFECTIOUS HAZARDS FROM NONHUMAN PRIMATES
Viruses
Bacteria
Macaques
Baboons
Guenons
Squirrel
Monkeys
Chimpanzees
B virus
Foamy virus
Simian retrovirus
(Type D)
SV40
SIV
Pox viruses
Yellow fever
Dengue
Ebola
Burkholdria
pseudomallei
Campylobacter spp.
Mycobacterium
tuberculosis
Mycobacterium bovis
Mycobacterium leprae
(also known to occur
in mangabeys)
Leptospira spp.
Salmonella spp.
Shigella spp.
Yersinia
pseudotuberculosis
Yersinia enterocolitica
Foamy virus
Pox viruses
Yellow fever
Dengue
Foamy virus
SIV
Pox viruses
Yellow fever
Dengue
Dengue
Yellow fever
Campylobacter spp.
Leptospira spp.
Mycobacterium
tuberculosis
Mycobacterium bovis
Salmonella spp.
Shigella spp.
Yersinia
pseudotuberculosis
Yersinia enterocolitica
Campylobacter spp.
Leptospira spp.
Mycobacterium
tuberculosis
Mycobacterium bovis
Salmonella spp.
Shigella spp.
Yersinia
pseudotuberculosis
Yersinia enterocolitica
Campylobacter spp.
Leptospira spp.
Mycobacterium
tuberculosis
Mycobacterium bovis
Salmonella spp.
Shigella spp.
Yersinia
pseudotuberculosis
Yersinia enterocolitica
Foamy virus
SIV
Hepatitis B
Molluscum
contagiosum
Hepatitis A
Pox viruses
Yellow fever
Dengue
Ebola
Burkholdria
pseudomallei
Campylobacter spp.
Mycobacterium
tuberculosis
Mycobacterium bovis
Mycobacterium
leprae
Leptospira spp.
Salmonella spp.
Shigella spp.
Yersinia
pseudotuberculosis
Yersinia
enterocolitica
Hymenolepis nana
Oesophagostomum
spp.
Strongyloides spp.
Trichuris spp.
Oesophagostomum
spp.
Strongyloides spp.
Trichuris spp.
Hymenolepis nana
Trichuris trichuria
Balantidium coli
Cryptosporidium spp.
Entamoeba histolytica
Giardia intestinalis
Plasmodium spp.
Balantidium coli
Cryptosporidium spp.
Entamoeba histolytica
Giardia intestinalis
Plasmodium spp.
Balantidium coli
Cryptosporidium spp.
Entamoeba histolytica
Giardia intestinalis
Plasmodium spp.
Trypanosoma cruzi
Hymenolepis nana
Oesophagostomum
spp.
Strongyloides spp.
Trichuris spp.
Enterobius
vermicularis
Balantidium
coli
Protozoan
Cryptosporidium
spp.
Parasites
Entamoeba histolytica
Giardia intestinalis
Plasmodium spp.
Metazoan
Parasites
Hymenolepis nana
Oesophagostomum
spp.
Strongyloides spp.
Trichuris spp.
Enterobius
vermicularis
Balantidium coli
Cryptosporidium spp.
Entamoeba
histolytica
Giardia intestinalis
Plasmodium spp.
Source: Occupational Health and Safety in the Care and Use of Nonhuman Primates (2003), Institute for
Laboratory Animal Research
22
23
24
25
26
30. Purpose of Testing:
31. Type of Injury:
1. Symptomatic, 2. Injury Baseline Testing, 3. Injury Follow-up Testing, 4. Routine,
5. Write a specific reason
1. Bite, 2. Eye Splash, 3. Animal Scratch, 4. Cage or Equipment Scratch, 5. Needlestick,
6. No Injury, 7. Write a specific reason
27
28
Description of Common Non-Human Primate Procedures at BUMC and Required Eye/Face Personal
Protective Equipment
Procedure
Eye/Face/Mucous Membrane
Protection
NHP Cage Changing
goggles and surgical mask
NHP dental cleaning
NHP Live Animal
Transport or Removal
to Transport Cage
Anesthetized NHP
Animal transport
goggles and surgical mask
Alternative, if available
safety glasses, face shield and
surgical mask
n/a
goggles and surgical mask
safety glasses, face shield and
surgical mask
goggles and surgical mask
safety glasses, face shield and
surgical mask
NHP Surgery on
Anesthetized Animal
using Surgical
Microscope
Safety Glasses (prescription if
needed) with Surgical Loupes,
Surgical Mask for Lead Surgeon, All
surgical assistants in room should
wear goggles and surgical mask
Lead surgeon currently wearing
prescription eyeglasses with side
shields and surgical loupes over the
glasses with a surgical mask.
Alternatively, surgical assistants can
wear safety glasses, face shield, and
surgical mask
NHP Surgery on
Anesthetized Animal
using Surgical Loupes
Safety Glasses (prescription if
needed) with Surgical Loupes,
Surgical Mask for Lead Surgeon, All
surgical assistants in room should
wear goggles and surgical mask
Lead surgeon currently wearing
prescription eyeglasses with side
shields and surgical loupes over the
glasses with a surgical mask.
Alternatively, surgical assistants can
wear safety glasses, face shield, and
surgical mask
Tracheal Tube
Insertion and Removal
during the beginning
and end of NHP
Surgery
goggles and surgical mask
safety glasses (prescription if needed),
face shield and surgical mask
Perfusion of NHP at
Termination Surgery
Completed in Fume Hood by Lead
Surgeon: Involves slicing of heart
ventricles, NHP anesthetized
Completed in Fume Hood by Lead
Surgeon: Currently wears
prescription eyeglasses and surgical
loupes and surgical mask
Magnetic Resonance
Imaging of NHP
Anesthetized Animal
Anesthetized animals in sealed
microisolator cage, safety glasses and
surgical mask should be worn
n/a
29
30
EMPLOYEE BITE AND SCRATCH LOG
Date
Employee
Type of Injury
Animal
Specimen
Sent
B Virus Culture
Received
Results
Employee Health
Provider Follow-up
Date
Contact
Initials
31
32
Boston Public Health Reporting Requirements
Employee/Personnel: Within 1 Business Day
Illness
•
All personnel and laboratory workers are encouraged to report any illness to their supervisor and occupational health
directly if they are ill and working with or near agents covered by this BPHC regulation.
•
Supervisors should refer any ill worker to the Occupational Health Officer (OHO) or designee for evaluation at Boston
Medical Center Occupational & Environmental Medicine located at 732 Harrison Avenue, (F5) or the Emergency
Department located at the Menino Pavilion at 771 Albany Street for after hours, weekends and on hospital holidays.
•
Supervisors are required to report all illnesses, significant exposures, and absenteeism to the OHO at (617) 353-6630,
(617) 738-4402, or (617) 780-5519 or designee at (617) 414-8262 or (617) 638-8400. The above conditions are
reportable to Boston Public Health Commission (BPHC) by OHO or designee.
Significant Exposures
•
All laboratory workers must report any exposures to their supervisor and occupational health directly.
•
Workers in laboratories working with agents covered by the BPHC regulations must be evaluated by the OHO or
designee prior to return to work if exposure to agents covered by these guidelines occurs.
Absenteeism
•
Worker notifies supervisor of reason for absence from work.
•
Supervisor contacts the OHO or designee. If employee is febrile or symptomatic he/she will need to be evaluated by
the OHO or designee. The employee must contact the OHO on day 1 of illness and be evaluated, depending on the
symptoms reported and also prior to returning to work if symptoms are potentially consistent with exposure
to agent.
Occupational Health Officer (OHO) or Designee: Within 1 Business Day
Illness
•
OHO or designee will perform an occupational health assessment for any employee who: (1) has been diagnosed, (2)
is exhibiting symptoms, or (3) may have been exposed to a registered agent as defined in this regulation.
•
OHO or designee shall immediately notify the BPHC of the assessment, but not later than one business day of the
assessment.
•
OHO or designee should evaluate the individual based upon clinical findings and epidemiological risk factors, including
specific lab work being conducted, and make appropriate recommendations.
•
OHO or designee shall report findings of the assessment immediately, but not later than one business day.
Significant Exposures
•
OHO or designee shall report to the BPHC any diagnosis of any disease caused by a high–risk registered agent pursuant
to Section V. Part A of the guidelines, and any violation or breach of any laboratory procedures or any other incident
which the IBC, Project Director or OHO should reasonably believe was released beyond the work area must be reported
within once business day.
•
OHO or designee must evaluate workers in laboratories working with agents covered by the BPHC regulations if an
exposure to agents covered in these guidelines occurs.
•
OHO or designee must report significant exposures to BPHC within 1 business day.
•
Follow–up information must be provided to BPHC as requested.
•
OHO or designee must report to BPHC, if a significantly exposed worker develops illness that could be related to an
agent used in the laboratory and covered by these guidelines.
•
OHO or designee should evaluate the individual based upon clinical findings and epidemiological risk factors, including
specific lab work, and make appropriate recommendation.
Absenteeism
•
OHO or designee must evaluate any worker in a laboratory using agents covered by these guidelines who is absent
from the workplace due to illness for a period of two or more consecutive workdays.
•
OHO or designee must contact the ill worker to determine whether illness could be related to an agent covered by these
guidelines and used in the laboratory.
•
OHO or designee must be reported within 1 business day to the BPHC, if illness may be related to an agent covered by
these guidelines.
Occupational Health Officer (OHO) or Designee: Within 3 Business Days
Illness
•
If the OHO or designee determines that the illness is caused by an agent that is covered by these guidelines and may be
work–related, BPHC must be consulted within 3 business days before the worker is allowed to return to work.
Significant Exposures
•
OHO or designee must send BPHC documentation that an exposed employee was cleared to return to work within 3
business days of clearance.