Infection control is becoming a priority among veterinary professionals, and distributors have a role to play

People come to an awareness of veterinary infection control in just about as many ways as infections find their way to people. Some are pushed toward it through an unfortunate circumstance; perhaps they or a colleague contract a zoonotic disease.
Others learn the importance of it through the example of another person, such as a co-worker. “We had a technician in our practice who was interested in safety and occupational health,” recalls Joni Scheftel, DVM, MPH, DACVPM, State Public Health Veterinarian, Minnesota Department of Health. “She had us get a thyroid protector for the radiology room. And she always wore goggles when she did dentistry. I took note of that.”
Still others come to an appreciation of veterinary infection control from a totally different perspective. For example, Brigid Elchos, RN, DVM, DACVPM, began her career as a nurse. “In the orientation to the hospital where I worked, they taught us how to handwash,” recalls Elchos, who is State Public Health Veterinarian, Mississippi Board of Animal Health. “That was not the case when I went to veterinary school.”
Regardless of how veterinary professionals come to the gospel of controlling and preventing infection, if Scheftel, Elchos and others have their way, infection control will become part of all veterinary schools’ curricula. It will also be part of all veterinary practices’ training programs. And with good reason.

The risk
Approximately 868 of 1,415 known human pathogens are zoonotic, and approximately 132 of 175 emerging diseases that affect humans are zoonotic, according to the National Association of State Public Health Veterinarians. Global commerce, trade and travel continue to increase the potential for exposure to zoonotic pathogens.
For example, in 2003, an outbreak of monkeypox virus affected 71 individuals in six states, of whom 18 were veterinary personnel. “That really opened up people’s eyes,” says Scheftel, who, along with Elchos co-chairs the NASPHV Veterinary Infection Control Committee. “It was an emerging disease, never seen in the Western Hemisphere, and it shows up in Wisconsin. It was the HIV of veterinary medicine.” It turns out that infected animals caught in Africa were transported to the United States, where they came into contact with other animals meant to be pets. The disease was then transmitted to humans.
But not all zoonotic diseases are so exotic, points out NASPHV. Among the more commonly acquired infections are multidrug-resistant salmonellosis, leptospirosis, cryptosporidiosis, cat-associated plague, cat-associated spororichosis, methicillin-resistant S aureus infections, psittacosis and ringworm.
Approximately two-thirds of veterinary medical personnel are hospitalized or unable to work for considerable periods of time as a result of animal-related injury, according to NASPHV. According to one report, approximately 3 to 18 percent of dog bites and 28 to 80 percent of cat bites become infected. Needlestick injuries are quite common too. (Unlike in human medicine, where one of the greatest risks to the healthcare provider lies in accidentally sticking himself or herself with a needle that has been used on a patient, on the veterinary side, the needlestick-associated risk lies with accidental self-injection of vaccines. In a 1995 survey of 701 veterinarians, for example, accidental self-injection of rabies virus vaccine was reported by 27 percent of respondents, according to NASPHV. Among large-animal practice respondents, 23 percent had accidentally self-injected vaccines containing live Brucella organisms.)
Another issue is animal-to-animal transmission, points out Sheldon Rubin, DVM, of Blum Animal Hospital, a 10-veterinarian practice located just a few blocks south of Wrigley Field in Chicago. At issue are such diseases as canine kettle cough, canine infectious diarrhea and feline upper respiratory disease. “This leads to issues of cleanliness, ventilation and appropriate isolation,” says Rubin, who is president of the Illinois State Veterinary Medical Association and frequent guest on local and national TV shows, including Oprah Winfrey.

Wide range of pathogens
In human medicine, the primary infectious risks to healthcare workers are bloodborne pathogens, such as hepatitis B and C, and HIV, says Elchos. “But in veterinary medicine, that’s not the case. There are a wide range of pathogens across many species, and many possible ways pathogens can be transmitted. The degree of risk depends on agents, susceptibility of people, the route of transmission, all kinds of things.”
“One issue that occurs more frequently than we’d like to see in veterinary hospitals are scratches, animal bites and needle punctures - just working with animals,” adds Rubin, who has been with Blum since 1968.

State of the practice
As a nurse, Elchos observed that infection control in hospitals dealt as much with protection of the healthcare worker as the patient. But in veterinary school, she observed a much different emphasis. It was focused almost solely on the protection of the patient - preventing surgical wound infections, for example.
Scheftel became interested in infection control during 19 years of practice, roughly half with large animals, and half with small animals. Her interest began with a concern about occupational health. “As a large-animal veterinarian, I saw some terrible farm accidents,” she recalls. One farmer was killed by gases in a silo, while an 8-year-old boy died in a combine accident.
“After I graduated from veterinary school, I could see that it was critically important for veterinarians to wash their hands between cases, so I always did that,” she says. “But I noticed that handwashing was relatively rare in veterinary clinics, as it is in medical clinics.”
Shortly after the monkeypox outbreak, Scheftel was invited to speak to vets in Minnesota about responding to emergencies, including zoonotic diseases. “I thought it didn’t make sense to go through a laundry list of zoonotic diseases, but rather, to train people on how to protect themselves from any of them,” she recalls. “It caught on like wildfire.
“Odd as it sounds, though it had happened 20 years earlier in human medicine, it was a new concept that veterinarians should protect themselves better,” she notes.
Unlike human medicine, where bloodborne diseases are particularly threatening, veterinary staff are much more likely to contract diseases that are transmitted through the feces and urine of animals. Another threat is presented through aerosolizing, such as when lancing an abscess.
The physical layout of many veterinary clinics presents a big challenge to infection control, says Scheftel. “Most spaces in veterinary clinics have multiple uses,” she points out. Exhibit 1 is the central treatment room, where everything from minor surgery, lab work and dentistry are carried out. “It’s where the veterinarians go after they see their patients to review records; it’s where blood draws are done. There’s usually a cage for a sick animal that needs to be watched carefully. So you have lots of traffic, sick animals, well animals, people. It’s an efficient way to run a practice, but it’s not good for infection control.” And it’s not unheard of for clinic staff to wipe off an exam table and eat lunch on it. “So space is really an issue,” she says. “Then there are longstanding habits.”
Indeed, in many cases, veterinary staff - as their human medicine counterparts - simply don’t take the time to practice proper infection control techniques, such as handwashing, adds Elchos. Part of the reason is simply history. “A lot of the work they did was field work,” she points out. Opportunities to carefully wash one’s hands or don protective apparel were limited. “People got complacent,” she says. But there’s not much excuse for [failing to] handwash in today’s clinical practices.
“I also think - and this is across the board - that there’s always a communication issue,” Elchos continues. “It doesn’t matter if you’re talking about a veterinary practice or a business. Changes in infection control practices filter down to personnel in clinical practice much later. There’s still a gap between what we know and what we put into practice.”

The best defense
Appropriate training of staff should be the veterinary practice’s No. 1 defense against the spread of infection, says Rubin. “Too many veterinary hospitals [fail to] spend enough time training the staff on, one, appropriate cleaning, and two, ways to dilute chemicals appropriately,” he says. At Blum, the staff uses a bleach solution that must be diluted in a 1-to-30 ratio. “Some practices don’t provide appropriate dilution cups,” he points out. “Allowing staff to dump in what they think is an appropriate amount is unacceptable.
“Too many small practices hire people, then send them right to work without training,” adds Rubin. “That’s how accidents happen.” At Blum, new staffers must watch a tape on OSHA guidelines and pass an exam based on it. “[The onset of the AIDS epidemic] gave us a whole new realm to think about when it comes to handling human blood spills,” he adds.

Recommendations drawn up
Responding to what was perceived as a lack of awareness of infection control guidelines, the NASPHV assembled a committee to look at the issue, educate practitioners, and put forward a set of recommended guidelines or precautions for veterinary personnel to follow. Consultants to the committee included several physicians. “We felt [their presence] would bring some balance to the work we were doing,” says Elchos. “Also, they would have the most experience with the human recommendations. We wanted to be consistent and practical, and we wanted a scientific basis for our recommendations.”
In 2006, the organization published online its “Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel,” intended primarily for public health veterinarians. “The point was to get a document out so that people could look at it and make comments, and we could then improve it through their observations,” says Scheftel. Two years later, the organization did just that. A revised compendium was published in the Aug. 1, 2008 issue of the Journal of the American Medical Veterinary Association. The Compendium includes information on zoonotic disease transmission, veterinary standard precautions (including the use of personal protective equipment), vaccinations and record-keeping, as well as a model infection control plan for veterinary practices.
“In academia and the public health community, the veterinary standard precautions have been reviewed and received very favorably,” says Elchos. “That’s the first thing.” She is eager for clinical veterinary personnel to read and embrace the recommendations. Distributor sales reps can help by promoting supplies and personal protective equipment that support the precautions, she adds.
Indeed, sales reps have an opportunity and a responsibility, says Rubin. “If they’re trying to sell products that are infection control-related, No.1, they need to show the veterinarian it’s not a corrosive and it won’t corrode stainless steel; No. 2, they have to show that the product won’t leave an odor that will bother people; and No. 3, they have to show that it’s an effective virucidal at appropriate dilutions.”
Manufacturers can play a role as well. “Both distributors and manufacturers need to educate and spread the gospel of proper infection control procedures,” says Paul Girouard, medical sales manager, Sultan Healthcare. “Once the education issue is addressed, then comes compliance. Simple issues like hand hygiene need to be addressed on a regular basis. Product needs to be readily available for staff. If it’s top of mind, easy to use, and available for staff, you will see greater compliance.”
The NASPHV Infection Control Committee will meet this fall to discuss updating the compendium. One topic for discussion will be how to address the threat of methicillin-resistant S aureus, or MRSA. “This has become a bigger and bigger issue in veterinary medicine,” says Scheftel.

To view the “Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel” by the Veterinary Infection Control Committee of the National Association of State Public Health Veterinarians, go to the following URL: http://www.nasphv.org/Documents/VeterinaryPrecautions.pdf.

Sidebar 1:
Environmental infection control
Following are a few points regarding environmental infection control from the “Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel” by the National Association of State Public Health Veterinarians.
Environmental surfaces and equipment should be cleaned and disinfected between uses or whenever visibly soiled. Surfaces in areas where animals are housed, examined or treated should be made of nonporous, easily cleaned materials. During cleaning, adequate ventilation should be provided, and generation of dust that may contain pathogens should be minimized through the use of central vacuum units, wet mopping, dust mopping or electrostatic sweeping. Facial protection and control of splatter can minimize exposure to aerosols generated by brushing during cleaning activities.
Gross contamination must be removed before disinfection because organic material decreases the effectiveness of most disinfectants.

Sidebar 2:
Personal protective equipment
In its “Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel,” the National Association of State Public Health Veterinarians offers recommendations on personal protective equipment, protective actions to be taken during veterinary procedures, and environmental infection control, among other topics. Here are a few points regarding personal protective equipment from the Compendium that may be of special interest to Veterinary Advantage readers. To view the complete Compendium, go to http://www.nasphv.org/Documents/VeterinaryPrecautions.pdf.

Handwashing. Consistent, thorough hand hygiene is the single most important measure veterinary personnel can take to reduce the risk of disease transmission. Handwashing is preferred over the use of hand rubs because hands are routinely contaminated with organic material. However, alcohol-based hand rubs are highly effective against bacteria and enveloped viruses, and may be used if hands are not visibly soiled.

Gloves and sleeves. Gloves should be worn when an animal has evidence of disease or its medical history is unknown, and worn routinely when contact with feces, blood, body fluids, secretions, excretions, exudates and non-intact skin is likely. They should also be worn when cleaning cages, litter boxes and environmental surfaces.

Facial protection. Facial protection (e.g., surgical mask with goggles or face shield) should be used whenever exposures to splashes or sprays are likely to occur, such as those generated during lancing of abscesses, flushing wounds, dentistry, nebulization, suctioning, lavage and necropsy.

Respiratory tract protection. Although the need for disposable particulate respirators is limited, it may be appropriate in certain circumstances, such as during investigations of abnormal storms in small ruminants, abnormally high mortality rates among poultry, respiratory disease in an M bovis-positive herd, and ill psittacines.

Protective outwear. Lab coats, smocks and coveralls protect street clothes or scrubs from contamination. However, they are not fluid-resistant, and should not be used in situations where splashing or soaking with potentially infectious liquids is anticipated. Non-sterile gowns provide better protection than lab coats. Permeable gowns can be used for general care of animals in isolation, while impermeable gowns should be used when splashes or large quantities of body fluids are present or anticipated. Footwear should be suitable for the specific working conditions.