Postexposure Prophylaxis Instructions for Monkey B Virus and Training

Employee/Personnel First Aid & Postexposure Prophylaxis Instructions for Monkey B Virus and Training Employee Training 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 Burkholderia pseudomallei Campylobacter spp. Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium leprae (also known in to occur 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 Burkholderia 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 Protozoan Balantidium coli Parasites Cryptosporidium spp. 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. 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. Assamese Macaque Barbary Macaque Bonnet Macaque Rhesus Macaque Japanese Macaque Fromosan Rock Macaque Tonkean Macaque Celebes or Crested Macaque Long-Tailed or CrabEating Macaque Pig-Tailed Macaque Lion-Tailed Macaque Booted Macaque Tibetan Macaque Toque Macaque Herpes B Virus Prevention Standard Operating Procedure Title: Essential Safety Precautions and First Aid Measures for Animal Care and Research Personnel Handling Macaques Purpose: This SOP establishes strict requirements for safe handling of macaques and details the immediate post-exposure treatment for personnel who may be exposed to Herpes B virus Background Nonhuman primates of all types can harbor diseases that are infectious for personnel handling these animals. Human infection with B virus from macaque monkeys is a serious risk due to the high morbidity and mortality of the disease in humans. During the past five years several cases of B virus infection have caused deaths among person exposed to macaques in the United States. B virus (a.k.a., Herpesvirus simiae, Cercopithecine herpesvirus 1) is enzootic in rhesus (Macaca mulatta), cynomolgus (M. fascicularis) and other Asiatic monkeys of the genus Macaca. Prolonged or lifelong infection is typical. The detection of infection in macaques is difficult because, as with human oral herpes infection, affected animals are frequently asymptomatic. False negatives are known to occur in the serological monitoring of macaques for infection. Consequently, all animals not known to have originated from B virus-free sources must be assumed to be carriers. Personnel are at risk of contracting infection both through direct contact with infected macaques as well as by indirect contact with an environment contaminated by B virus. Virus may be present in macaque blood, saliva, tears, and genital fluids. Most human cases of B virus have resulted from direct inoculation by macaque bites or scratches or from working with infected macaque tissues. However, any exposure of broken skin or mucous membrane to potentially contaminated secretions or material places the individual at risk of infection. Person to person transmission also has been documented. Additional background information on B virus may be obtained from the references listed at the end of this document. Procedure The following requirements apply to the acquisition and handling of macaques: 1. Personnel working with macaques are required to review and sign a copy of this SOP acknowledging that they understand the nature of B virus hazard and that they will rigorously follow the precautions outlined below. 2. All macaque monkeys will be regarded as infected with B virus and are considered capable of transmitting the infection at all times. Consequently, direct handling of macaques must be minimized as much as possible. Macaques will be housed in squeeze-back cages that permit physical restraint to facilitate the administration of ketamine. When possible, macaques will be immobilized with ketamine anesthesia prior to initiation of procedures. Studies necessitating the handling of macaques without the protection afforded by animal immobilization must be conducted with strict adherence to safety requirements. 3. Extreme care must be taken to avoid accidental self-injury with needles or any other instruments that have been used for procedures on macaques. Post-injection needle re-capping is not permitted when working with macaques. All hypodermic equipment must be discarded in appropriate disposal units immediately after macaque injections are delivered. 4. Surgical instruments that have been used on macaques or macaque tissues must be handled with extreme caution to avoid injury. All items and instruments with any macaque tissue or bodily fluids must be appropriately discarded or decontaminated as soon as possible following use. Safety apparel and precautions apply until disposal or decontamination is complete. 5. Personnel who transfer macaques from one cage to another must wear a long-sleeved garment to prevent scratches and a chin-length wrap around face shield (or surgical mask plus goggles/safety glasses with solid side shields) to prevent exposure of mucous membranes (eyes and mouth) to macaque secretions. Leather gloves must also be worn while manipulating the cage during the animal transfer process. If personnel are working with chemically immobilized animals, latex or vinyl gloves may be worn instead of the leather gloves; eye protection and nose/mouth protection must be maintained. 6. Cages and other equipment used for macaque housing or procedures should be considered contaminated with infectious B virus. This equipment should be designed and maintained to prevent personnel injury from sharp edges or corners and be arranged in the animal housing area to minimize the risk of workers being accidentally grabbed or scratched by the animals. 7. Access to all areas where macaques are maintained or used must be restricted to workers who are properly trained in the methods listed in this SOP. All qualified individuals must also meet our institution's other criteria for nonhuman primate contact (see Occupational Health Program requirements). The essential criteria for nonhuman primate contact include baseline serum banking for retrospective studies of potential zoonotic disease transmission and participation in a program for tuberculosis screening. 8. A person who has received a needlestick, bite, scratch, other injury, or eye/mucous membrane splash that could possibly be contaminated with macaque blood, tissue, or secretions must: a) First, Wash the injury thoroughly for 15 minutes, by following the attached First Aid Instructions; and then: b) Report to the BMC Occupational and Environmental Medicine Clinic c) Follow–up on the next business day to BMC Occupational & Environmental Medicine and as directed if emergency care was provided by the Emergency Department and if any skin lesions or neurological symptoms (such as itching, pain, or numbness) occur near the site of the wound or if any unusual illness occurs following the injury. The BMC Occupational & Environmental Medicine will monitor the clinical status of the individuals for up to 12 weeks after an exposure. Symptoms suggestive of B virus infection must be reported immediately to the BMC OEM or to the ED after hours, weekends or holidays. Postexposure Contents of First Aid Kit For Wounds Involving Macaques 1. Cleansing materials a. Povidone-iodine or Chlorhexidine scrub concentrate b. Consider washing skin with 0.25% hypochlorite spray solution in spray bottle Fisher Scientific NC 9155788 c. Sterile surgical scrub brushes d. Sterile basin for soaking large wound scrub e. Sterile 4 x 4 gauze pads for dressing wound f. Telfa pad and tape for dressing wound g. Sterile saline solution for irrigation of contaminated eyes, nose, or mouth or eye wash h. Paper or cloth tape for dressing of wounds Additionally, to be included in kit if worksite does not have ready access to a sink with free flowing water. a. (2) Sterile saline solution (1L bottle) for irrigation of contaminated eyes, nose mouth. b. Dry irrigation bottle c. Basin 2. Instructional materials a. First Aid Instructions b. B-Virus Policy 3. Injury Incident Report Form NOTE: When macaques are present in the facility, the LASC technologist is responsible for checking the kit contents monthly to keep the components in stock and in date. Restricted Area ▼ ►◄ (Attach orange Biohazard Warning Symbol) Biohazard No Entry Unless You have Received and Signed the Macaque Handling SOP Room: Species: Hazard: CABR Building--W XXX M. mulatta (rhesus macaque) B virus (a.k.a., Herpesvirus simiae, Cercopithecine herpesvirus 1) introduced by bite, scratch, splash, or needlestick involving macaque or material (cage, needle, scalpel blade, etc.) that may be contaminated with macaque tissues Protective equipment required: Long-sleeved lab garment to protect arms Gloves to cover hands, plus heavy outer gloves for cage handling Surgical mask or facemask to cover nose and mouth Goggles or face shield to cover eyes In case of an emergency, consult instructions in First Aid Kit. ROLES AND RESPONSIBILITIES OCCUPATIONAL & ENVIRONMENTAL MEDICINE (OEM)/EMERGENCY DEPARTMENT (ED) is responsible for: a. b. c. d. Patient wound care Patient sample collection Patient information and post-exposure follow-up Sending patient samples to BMC Microbiology Laboratory on DOB H 416 for packaging ENVIRONMENTAL HEALTH & SAFETY (EHS) is responsible for: a. Investigation of the exposure. b. Communication of the incident investigation to the primary investigator, and LASC of any possible modification to the study protocol based on the required post exposure follow-up surveillance. c. Tracking animal exposure incidents. LABORATORY ANIMAL SCIENCE CENTER (LASC) is responsible for: a. Clinical evaluations of the monkey or monkey tissue. b. Animal sample collection packing and transport of samples to B-Virus Laboratory c. Define employee exposure groups and train employees on for the B-Virus Protocol Employees are responsible for: 1. Prevention of B virus infection must always be the first goal and can be achieved through the following measures: a. All macaque monkeys and their tissue should be regarded as infected. Viral shedding is intermittent and can occur in the absence of visible lesions. b. Handling of macaques should be minimized and should be done by trained personnel. c. Transfer and squeeze-back cages should be used to move monkeys whenever possible. d. Ketamine may be used to remove monkeys from cages, particularly large or difficult animals. e. Use appropriate personal protective gear. Use protective eyewear: (goggles/glasses with solid side shields and top shield), and a mask or a chin-length wrap around face shield and a mask is recommended to protect the mucous membranes of the worker. Long sleeved and long legged clothing, and gloves are necessary when handling animals or cleaning cages. f. Do not recap needles or sharps! g. Dispose of sharps (scalpel blades, contaminated sharp glass or needles) immediately after use in a designated, conveniently located puncture resistant sharps container. h. Surfaces in contact with monkeys or their fluids should be disinfected after use. i. Cages/equipment with potential for contamination from monkey fluids should be inspected for sharp edges that may cause injury to workers. j. Always practice appropriate hand cleaning techniques. k. Routinely report biohazard injuries. 2. First Aid: If a biohazardous injury occurs, risk of infection can be reduced by immediate first aid. a. Thoroughly cleanse/scrub/irrigate the wound topical antimicrobial agent (povidone iodine or chlorohexidine) for 15 minutes+. If eyes, mouth, nose or other mucous membranes have been exposed, irrigate the site for 15 minutes+ with sterile saline or rapidly flowing water. Consider 0.25% hypochlorite spray on wound, scratch or contacted area. Never use on mucous membranes or near eyes or mouth. b. After cleansing the injury, cover the injury (sterile dressing if available) and proceed to the Occupational & Environmental Medicine during business hours c. As soon as practical, report the injury to your supervisor. If possible, report the identification of the involved animal. 3. Injury Follow-Up: Know early signs and symptoms suggesting B virus infection and reports soon as possible for physician evaluation if any of the following signs or symptoms occur: Make sure that you inform any treating provider that you have been exposed to B-Virus and bring your information with you, if you are traveling. a. b. c. d. e. f. g. h. Vesicular lesions near injury site Localized numbness, itching, pain, tingling Regional lymph node enlargement Fever Muscle weakness Conjunctivitis Stiff neck, headache, nausea, blurred vision If initially seen in the Emergency Department report to OEM on the next business day for follow-up. If a baseline blood specimen was sent for B virus serology you must make an appointment to have a follow-up serology drawn 2-3 weeks after the biohazard exposure. Supervisors or Principal Investigators are responsible for: 1. Prevention Train employees on the risk of B virus infection, the methods of preventing B virus infection, the need to clean wounds immediately for 15 minutes, and the importance of reporting injuries and/or symptoms to supervisors. 2. First Aid If present at the time of the injury, assist the injured employee to cleanse the wound. If wound is bleeding, take care not to directly contact employee’s blood without using Standard Precautions. 3. Reporting If possible, identify the animal causing the injury and notify the staff veterinarian to review the animal’s record, examine the animal and collect specimens on the animal for appropriate laboratory tests. 4. Supervisor's completes the Accident Report and Analysis form. The BMC Emergency Department (East Newton Campus) (BMC ED ENC) is responsible for: 1. Treating Macaque related biohazard injuries that require suturing or other emergency care. 2. Patient should be referred for follow-up on the next business day at OEM and given written information regarding serious potential symptoms. 3. The attending ED physician should rapidly review the adequacy of the previously administered first aid. Repeat wound/exposure site cleaning and provide prophylaxis if indicated with Tetanus, Augmentin, (wound or bite) and consider B Virus prophylaxis. 4. Instruct the exposed employee to make a follow up appointment with the BMC Occupational & Environmental Medicine (617-638-8400) or contact the Infectious Disease Physician on call for admission to the hospital of symptomatic patients. 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 others exposed to fecal contamination Personal protective equipment; Hepatitis A vaccine is now a good hand washing; offer hepatitis routine immunization for travelers A vaccine; 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. Bite wound infection Macaque handlers 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. Rabies Macaque handlers Observe animal after bite; if becomes ill, then consider testing for rabies and beginning immunization of worker; It is unlikely that these previously quarantined primates would contract rabies.