The University f Queensland, Schl f Veterinary Science Bisecurity and Infectin Cntrl Prcedures: Equine Hspital (Gattn) This dcument utlines the prtcls and standard perating prcedures (SOPs) fr bisecurity at the Equine Hspital at the Gattn Campus. All staff r students entering the Equine Hspital must have read these bisecurity guidelines. All staff must have undergne a staff hspital inductin, including basic bisecurity training. Students must have undergne an inductin and rientatin sessin (unless under cnstant supervisin by a member f hspital staff). UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Equine Hspital Bisecurity: Minimum hygiene standards These measures are t be implemented at all times, fr all patients, as the minimum standard Basic clthing, persnal hygiene and entry/exit prcedures All staff and students having cntact with hrses are t wear apprpriate clthing within the hspital, either: Overalls (nt t be wrn utside the hspital) Scrubs (nt t be wrn utside the hspital) Apprpriate ftwear (cvered shes, preferably bts) t be wrn at all times within the hspital Shes must be clean (n mud, n manure) prir t entry t the hspital All persns entering and exiting the hspital t wash hands and arms t the elbw at the basin prvided at the hspital entry. Paper twels t be used. Jewellery shuld nt be wrn n hands r arms. If a watch is wrn, it must be capable f thrugh disinfectin (ie suitable fr immersin in disinfectant) Any equipment that is carried in and ut f the hspital (e.g. stethscpe) must be disinfected with alchl-based disinfectant gel (Micrshield Angel antimicrbial hand rub cleanser prvided n the dr f every stable and thrughut the hspital) Lng hair shuld be tied back. All hrse wners and visitrs must be accmpanied by a member f staff wh is t ensure cmpliance with bisecurity prtcls. Laundered veralls and scrubs are available daily t staff. Students t prvide their wn clth veralls; these shuld be kept separately frm ther clthing and equipment after wearing (eg in a garbage bag) and laundered in ht water after each use. Patient handling (minimum standards fr all patients regardless f disease status) Glves (latex r nitrile) t be wrn at all times when examining new patients r handling hspitalised patients. Glves are prvided n all stable drs and thrughut the hspital. Disinfect hands with alchl-based disinfectant gel (Micrshield Angel antimicrbial hand rub cleanser prvided n the dr f every stable and thrughut the hspital) befre and after handling every patient Wash hands thrughly with Micrshield chlrhexidine sap (prvided ver sinks) under running water if hands cme in cntact with any faeces r bdy fluids All patients must be triaged n/prir t arrival and assigned a bisecurity classificatin as described belw. Prcedure-based requirements fr PPE fr nrmal hrses are utlined in Table 1 UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Dispsal f waste Siled dressings and clinical waste t be remved frm wrk areas and placed in bihazard bins (yellw liner) fr apprpriate dispsal (incineratin) Apprpriate bins are prvided and changed nce t twice daily r mre if required; wear glves while changing and disinfecting bins All wrk areas are t be cleaned and disinfected immediately after prcedure is cmpleted Siled bedding t be dispsed f away frm the hspital in accrdance with lcal cuncil regulatins Sharps t be dispsed f immediately after use in designated sharps cntainer. Cleaning and disinfectin f equipment between patients This includes husbandry equipment (such as halters, twitches) and medical equipment (such as endscpes, muth gags, stethscpes, nasgastric tubes etc) must be cleaned and disinfected prmptly after use Cntaminated r dirty clthing shuld be changed prir t examinatin f the next patient Hspital rm and stable cleaning prtcls Wherever pssible, cntaminatin f the hspital envirnment shuld be minimised: All hrses shuld have feet picked ut prir t remval frm their stable (hf pick prvided n all stable drs) Faeces, urine and ther bdy fluids shuld be cleaned as sn as pssible frm the wrk area r frm crridrs Hspital flrs t be cleaned daily; all impervius surfaces (flrs, bench tps, cupbards etc) t be cleaned with detergent daily; Prus surfaces (walls, ceilings) t be cleaned regularly t prevent build-up f dust and cbwebs. All stables will be cleaned and disinfected between patients using standard prtcls: See Stable cleaning and disinfectin prtcls belw UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Stable cleaning and disinfectin prtcls After a hrse leaves the stable and prir t a new hrse entering: 1. Remve all bedding and manure. The activity f disinfectants is decreased in the presence f rganic debris s in rder t maximize the effectiveness f disinfectin it is imprtant t include a detergent cleaning step in additin t physical remval f bedding and manure. 2. Clean all surfaces with an aninic detergent (fllw recmmended dilutin n pack) Detergent slutin can be delivered using a Hydrfamer (set t apprpriate dilutin Fr sme cntaminated areas r equipment it may be necessary t use a hand-sized brush and be sure t disrupt all surfaces that animals r faecal material may have cntacted. 3. Rinse with clean water. 4. Apply a dilute slutin (1:50 dilutin f 5% sdium hypchlrite) f bleach and allw at least 10 minutes cntact time. Fr small areas r equipment, bleach can be applied with a mp r brush. Mre efficient applicatin f bleach with better cverage and lnger cntact time can be btained by using a Hydrfamer filled with 3 parts bleach t 1 part aninic detergent. 5. Rinse thrughly with clean water and allw the treated area t dry as much as pssible. 6. Spray walls and flr with a perxygen disinfectant: 2% Virkn -S delivered using a back-pack pump sprayer, gas-pwered sprayer r similar When spraying Virkn -S r similar agents a mask (fit-tested type such as P- 2) and glves must be wrn as well as safety gggles. Allw 10-20 minutes cntact time fr Virkn -S. 7. The area may be rinsed with clean water but as the xidizing activity f Virkn -S dissipates ver a relatively shrt perid f time this is nt essential. 8. Drying is imprtant t achieving maximum effect s allw the area t dry as much as pssible befre re-bedding r reintrducing animals. When using any cleaning and disinfecting agents it is essential that the Material Safety Data Sheet (MSDS) fr each prduct be cnsulted and the guidelines fr prper mixing, use, dispsal and any specific precautins be carefully fllwed. In particular, the recmmendatins fr apprpriate Persnal Prtective Equipment e.g., glves, eye prtectin etc. must be strictly adhered t. UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Other cnsideratins fr stall cleaning: Remember, dirt cannt be disinfected. Remval f grss rganic debris prir t cleaning and disinfectin f slid, nn-prus surfaces is critical All stall equipment such as buckets and feed tubs, shuld als be thrughly cleaned; scrub with a brush using an aninic detergent, rinse, and then apply a bleach slutin (1:50 dilutin f 5% sdium hypchlrite). Spraying with 2% Virkn -S shuld be used as a final step with high risk r knwn psitive animals. Equipment that is used fr feed and water shuld be allwed t dry and then be rinsed thrughly with clean water befre reusing. Stall cleaning equipment; brms, shvels, pitchfrks etc., shuld als be cleaned using a detergent and a brush t remve grss debris fllwed by immersin f the equipment s head in 2% bleach slutin and wiping dwn f the handles. Such equipment can als be saked in tubs f disinfectant (e.g., Nlvasan [chlrhexidine], 2 z per galln). Drying in the sun is helpful. Fr equipment such as muzzles, brushes, lead shanks, twitches, halters, etc., sme disinfectants will cause certain materials such as rubber t deterirate: be sure t read the label t check that a disinfectant is safe t use with a given material. In general, clean ff grss debris with aninic detergent using a spnge r brush, then sak fr apprximately 1 hur in drums r buckets cntaining an apprpriately diluted chrhexidine slutin. Be aware that it is unlikely that everything in the animal husing/handling envirnment is cmpletely cleanable. Prus surfaces with intact finishes such as painted r varnished wd can be cleaned but items with surface damage r thse that are made up entirely r in part f prus materials are much mre difficult t clean and may be impssible t disinfect cmpletely. Fr example, nyln rpes can be immersed in disinfectant fr several hurs and then allwed t dry, but a fully prus material such as a cttn lead rpe cannt be prperly disinfected. UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Equine patient bisecurity triage and classificatin at admissin In terms f hspital bisecurity, the mst imprtant infectius rganisms carried by hrses are: Salmnella spp (z) Clstridium difficile (z) Cryptspridium spp (z) Streptcccus equi equi (Strangles) Methicillin Resistant Staphylcccus aureus (MRSA) (z) Equine herpes virus 1 (neurlgic/abrtin frm) Hendra virus (z) (z) Signifies zntic ptential The identificatin f hrses that are suspected f/cnfirmed t be carrying these rganisms is imperative, as preventin f transmissin will require bisecurity precautins in additin t the minimum standards described abve Cases can be divided int the fllwing 3 categries based n clinician assessment and histry: 1) Lw Risk - N signs r histry f systemic illness (n fever, n diarrhea) - Includes mst cases presented fr elective/rutine prcedures and fr musculskeletal injury 2) Medium Risk - Hrse has nn-specific clinical signs f systemic disease, including any f the fllwing: Pyrexia Clic Neurlgical dysfunctin Acute respiratry signs (dyspnea, nasal discharge etc.) Histry f recent abrtin (last 7 days) 3) High Risk - Hrses with clinical signs that are highly suggestive f active disease caused by the rganisms mentined abve. This includes: Hrses with diarrhea (at admissin) Hrses that have a cmbinatin f acute neurlgical disease and pyrexia Hrses with acute disease cming frm a prperty where there has been recent, undiagnsed acute death in ther in-cntact hrses Hrses where ne f the rganisms mentined abve has been cnfirmed by labratry testing - Any ther hrse where there is significant cncern f cmmunicable, extic r zntic disease, at the discretin f the admitting clinician UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Prtcls fr admissin, handling and treatment based n bisecurity classificatins: 1) Lw Risk - Husing and handling accrding t minimum standards described abve - Prcedure-based PPE nly (as described in Table 1) 2) Medium Risk - Husing and handling accrding t minimum standards, - Prcedure-based PPE nly (slightly higher level, as described in Table 1) - If unvaccinated, these hrses shuld be tested fr Hendra Virus as sn as pssible Nasal swabs and EDTA bld submitted fr PCR analysis If the Hendra virus PCR is negative, and depending n clinical signs, the hrse may be dwngraded t the Lw Risk categry at the discretin f the clinician respnsible fr the case 3) High Risk - These hrses shuld nly be admitted t the islatin facility, and shuld be hused in islatin stalls - Standard islatin prtcls (including PPE) t be fllwed fr all prcedures (see belw) - These hrses must be tested fr Hendra Virus as sn as pssible (prir t admissin if clinical signs are highly suggestive) Nasal swabs and EDTA bld submitted fr PCR analysis If the Hendra virus PCR is negative, and depending n clinical signs, the hrse may be dwngraded t the Lw Risk categry at the discretin f the clinician respnsible fr the case - Hrses shuld underg labratry testing fr ther specific rganisms mentined abve, as deemed apprpriate by the clinician respnsible fr the case - Hrses with clinical signs that are highly suggestive f Hendra virus r EHV1 (abrtin/neurlgical frm) shuld nt be admitted t the hspital (until apprpriate tests have shwn the hrse t be free f these diseases). UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Initial case triage Fr all emergency cases (ie nn-elective evaluatins) a senir clinician must discuss the case by phne with the client r referring veterinarian prir t accepting the case fr admissin Clients shuld be instructed that they shuld nt begin travelling with the hrse until they have cnfirmed with a senir clinician that the case will be accepted. Fr any ptential emergency case, the senir clinician n duty shuld ascertain HeV vaccinatin status Clinical presentatin The senir clinician may advise the client/referring veterinarian that the case cannt be admitted based n clinical suspicin f infectius disease that presents a bisecurity risk. This may include suspicin f HeV, EHV1 (neurlgic/abrtgenic) r ther disease and is at the discretin f the senir clinician n duty. If there is dubt, the case shuld always be discussed with at least ne f the large animal internal medicine specialists and r the Hspital Directr. All emergency cases where a histry f HeV vaccinatin is claimed shuld be cnfirmed by micrchip scan and crss checking with the registry at the earliest cnvenience Current vaccinatin fr HeV des nt alter the requirement fr prcedure-based PPE as utlined in Table 1. UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Obtaining and submitting samples fr Hendra virus testing Cntact the Labratry Liaisn Officer befre sending any samples Call (07) 3276 6062 (business hurs) r email bslcl@deedi.qld.gv.au Samples shuld nly be btained by staff wearing apprpriate PPE (see Table 1) A range f samples can be taken frm live hrses generally a nasal swab and EDTA bld will be sufficient Sample dispatch: Samples must be packaged apprpriately training will be prvided t staff Samples must be dispatched t a gvernment veterinary labratry in the shrtest time pssible. Ntify the labratry that HeV samples are cming by telephning the Labratry Liaisn Officer n (07) 3276 6062. Fill ut a specimen advice sheet (SAS) with all details, including a thrugh histry. Place the SAS utside the sample package s it can be read befre the package is pened. A cpy f the SAS is available frm the Bisecurity Queensland website (www.bisecurity.qld.gv.au). Click n Animal health & diseases > A-Z list > Hendra virus > Submitting samples fr analysis (under Fr veterinarians ) > Specimen advice sheet (under Sample submissin frms ). Clearly write HENDRA VIRUS EXCLUSION URGENT PRIORITY n the SAS. Samples shuld be kept refrigerated, NOT frzen. UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Table 1: Prcedure-based persnal prtective equipment (PPE) prtcls fr UQ Equine Hspital Theses prtcls are aimed at minimising the zntic risk f diseases including Hendra virus, as well as the spread f infectius disease t ther hrses. Prcedure Case Classificatin Lw Risk - N systemic illness - Lameness cases, elective surgery Medium Risk - Systemically ill hrses, with e.g. fever, clic, respiratry disease (prir t definitive diagnsis) High Risk - Hrses with diarrhea upn admissin - In cases where there is a high suspicin f Hendra virus (based n histry and/r clinical signs) - Cnfirmed r highly suspicius Strangles cases Prcedures invlving n/minimal cntact with bdy fluid - General handling - Lameness examinatin - Auscultatin - Radilgy, ultrasund 1. Minimum hygiene standards 1. Minimum hygiene standards Hrses t be mved t islatin facility. Observe islatin prtcls and PPE - Impervius dispsable veralls - Impervius bts - Nitrile glves - Prtective eyewear and P2 mask (if HeV suspect) Prcedures that invlve nn-aerslised bdy fluid cntact - Rectal examinatin - General surgery - All injectins - Venipuncture - Cllectin f fluid frm cavities (eg thraccentesis) 1. Minimum hygiene standards 1. Minimum hygiene standards 2. Face prtectin: - Prtective eyewear - P2 mask r - Plastic face shield Hrses t be mved t islatin facility. Observe islatin prtcls and PPE - Impervius dispsable veralls - Impervius bts - Nitrile glves - Prtective eyewear and P2 mask (if HeV suspect) Prcedures that invlve cntact with aerslised bdy fluid and ptential inhalatin - Dentistry - URT endscpy - Nasgastric intubatin - Nasal swab - BAL 1. Minimum hygiene standards 2. Face prtectin: - Gggles - P2 mask r - Plastic face shield 1. Minimum hygiene standards 3. Face prtectin: - Prtective eyewear - P2 mask 2. Impervius gwn r veralls Hrses t be mved t islatin facility. Observe islatin prtcls and PPE - Impervius dispsable veralls - Impervius bts - Nitrile glves - Prtective eyewear and P2 mask (if HeV suspect) UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Equine Islatin Prcedures Admissin t islatin Hrses t be admitted t islatin stalls nly if authrised by clinician respnsible fr the case Hrses cnsidered high risk based n histry shuld be admitted t islatin upn arrival at the hspital (eg. cases with diarrhea) Based upn infrmatin prvided ver the phne, cases with clinical signs r histry that is highly suspicius f Hendra virus r EHV1 (neurlgical/abrtin frm) will nt be permitted t cme t the hspital. Instead, the caller will be advised by the clinician n duty t cntact their regular veterinarian t pursue apprpriate prcedures/testing. Staff and student entry/exit prcedure and PPE requirements fr islatin cases Human entry shuld be kept t the minimum necessary. Where pssible, treatment times shuld be synchrnised t minimise unnecessary entry In general, entry by staff/students t islatin stalls shuld be left t last if a batch f prcedures is being perfrmed acrss the hspital (e.g. stable cleaning, mrning r afternn treatments) Entry prcedure fr islatin stalls: Dn latex glves and impervius bt cvers at the entry t the islatin area (kept at perimeter gate) Enter islatin stall ante rm Dn nitrile glves (ver latex), rubber ver-bts and impervius dispsable veralls Dn prtective eyewear/face shield and P2 mask (if HeV suspect nly) Walk thrugh Virkn-S ft bath Enter patient stall via internal stall dr Exit prcedure fr islatin stalls: Exit stall via internal stall dr int ante rm Remve uter pair f glves and dispse in prvided bin Remve impervius dispsable veralls and dispse in infectius waste bin Wash hands (still inside latex glves) with chrhexidine sap and water Remve mask and gggles (if applicable) Walk int Virkn-S ft bath and scrub bts (sles and walls) using brush prvided, taking care t remve any grss cntaminatin and t cver the entire surface with Virkn-S Remve bts n ther side f ft bath and place back n rack. Exit stall Walk t islatin area perimeter gate and remve impervius bt cvers and latex glves, dispsing in prvided bin Walk acrss Virkn-S mat Disinfect hands with alchl-based disinfectant gel (Micrshield Angel antimicrbial hand rub cleanser) Exit islatin area UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Islatin equipment and cleaning prtcl Islated patients must have their wn equipment including thermmeters, stethscpes, halters, lead rpes, buckets, NG tubes, funnels, stall cleaning equipment; Disinfectant ft baths/mats must be cleaned and re-stcked daily (r mre ften if cntaminated with rganic material) Islatin stalls must be cleaned last r preferably by different persnnel than thse cleaning nn-islatin stalls. Drugs, feed, bedding and ther cnsumables that enter the islatin area must nt leave the islatin area (except as waste) All waste frm the islatin area must be dispsed f in the prvided infectius waste bins Equipment that must enter/leave islatin temprarily (e.g. x-ray equipment) must be cleaned and disinfected after use and befre leaving the islatin area (use apprpriate disinfectant accrding t specific equipment materials) Stall and equipment cleaning between cases shuld be perfrmed using the multiple step prtcl described in Stable cleaning and disinfectin prtcls abve, and must include all stable-cleaning equipment t be re-used in the stall. Islatin stalls that have hused diarrhea cases r cases that have had psitive faecal Salmnella cultures must have 2 cnsecutive negative envirnmental cultures befre the next hrse can be accepted Islatin bedding dispsal The clinician respnsible fr the case will cnfirm with barn staff hw the bedding fr each islated case is dispsed f. If stall cntents cnsidered by attending Clinician t have a zntic ptential (Cnfirmed Salmnella, Cryptcccus) all waste t be treated as Bihazard (ie yellw bins with yellw bin liners) and ACE waste utilised fr subsequent incineratin. Nte that in all cases f cnfirmed Hendra Virus Bisecurity Queensland will direct quarantine measures and waste management If stall cntents cnsidered by attending Clinician t cnstitute a risk t hrse health all waste t be treated as Bihazard (ie yellw bins with yellw bin liners) and ACE waste utilised fr incineratin. If stall cntents cnsidered by attending Clinician t be f n r minimal risk t hrse health then bedding is dispsed f as per regular arrangement Nte :- all PPE used within Islatin is t be dispsed f thrugh Bihazard / Clinical Waste Bins within Islatin and n n accunts shuld be dispsed f thrugh general waste. UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Barrier precautins and islatin prcedures fr hrses that develp clinical signs f infectius disease whilst in hspital Hrses that develp clinical signs f ptentially infectius disease (eg diarrhea) shuld be cnfined t their stall, with barrier precautins applied t entry/exit, until further testing A small area arund the entry t the stall is islated with tape A stall-side ft bath f Virkn-S is prvided Apprpriate PPE is prvided fr dnning/dffing within the taped area, including impervius bt cvers, impervius gwns (r veralls), nitrile glves, and gggles/masks (if applicable) All waste (including bedding) is treated as infectius waste and dispsed f in apprpriate bins placed within taped area Hrse mvement is minimised Equipment must nt be shared with ther hrses, and must be cleaned and disinfected if remved frm the stall area A flw chart specifically fr diarrhea, fever and leucpenia (suspect Salmnella spp.) is shwn in Figure 1. belw Remval f barrier precautins, r (alternatively) mvement f the hrse t an islatin is based n: Results f testing Prgressin r reslutin f clinical signs Discretin f the clinician respnsible fr the case Hspitalised hrses that develp highly suspicius clinical signs, r that return a psitive test fr Hendra virus, must be placed immediately in islatin (by staff wearing apprpriate PPE) and Bisecurity Queensland must be immediately ntified (13 25 23 r 1800 675 888). UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Figure 1. Barrier precautins and islatin f cases with diarrhea, leucpenia and/r pyrexia Definitins - Leucpenia: WCC less than 4x10 9 /L - Fever: multiple instances f rectal temperature increase t greater than 38.5 C in a 24 hur perid - Diarrhea: sft/liquid manure retaining n shape in the bedding passed mre than twice in a 12 hur perid - Barrier precautins: stp mvement f patient and cnfine t stall, warning tape arund patient stall, dispsable bts, gwns/veralls, nitrile glves, and 2% Virkn ft bath prvided stall-side - Culture Series: Series f three faecal Salmnella cultures (reflux can be used in absence f faeces) submitted n cnsecutive days. - A psitive Salmnella culture in the presence f clinical signs mandates mving t islatin facility UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
Human expsure t Hendra virus and ther znses Any staff r students that have been expsed t bilgical materials frm a suspected r cnfirmed infectius zntic case shuld reprt t the clinician in charge f the case, and shuld immediately be referred t the Gattn campus medical staff In the event f a Hendra virus psitive case, Bisecurity Queensland will cntact Queensland Health as per an agreed ntificatin prtcl. Queensland Health will decide whether any peple require mnitring and/r medical assistance. If any persn is cncerned abut their health, they shuld reprt their cncerns t the senir clinicians immediately, and they shuld then be referred t the Gattn campus medical staff Extic/emergency animal diseases affecting equines 1 African hrse sickness Anthrax Australian lyssaviruses (including b at lyssavirus) Brucellsis Cntagius Equine Metritis Durine Equine babesisis (pirplasmsis) Equine encephalmyelitis (Western Eastern & Venezuelan) Equine encephalsis Equine influenza Glanders Hendra Virus Japanese Encephalitis Ptmac fever Rabies Screw Wrm fly Surra Vesicular stmatitis Ntificatin prcedure: Ntificatin f extic/ntifiable diseases can be made by cntacting ne f the fllwing: Bisecurity Queensland n 13 25 23 (business hurs) Emergency Animal Disease Watch Htline n 1800 675 888 (24 hurs). 1 See Ausvetplan UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps
REFERENCES & RESOURCES Bisecurity QLD Guidelines: http://www.dpi.qld.gv.au/dcuments/bisecurity_generalanimalhealthpestsanddiseases/hendra- GuidelinesFrVets.pdf Ausvetplan: http://www.animalhealthaustralia.cm.au/prgrams/eadp/ausvetplan/ausvetplan_hme.cfm UQ Equine Hspital Bisecurity Prtcl 9.3.2015 Andrew van Eps