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Biosecurity and public health challenges in veterinary facilities with special reference to India and other developing countries.

Introduction

The focus of this paper is on biosecurity issues and concerns in general and in particular in developing countries viz India. The ultimate goal is infectious and zoonotic disease prevention in animal patients, animal health workers and our clients in veterinary practice. The situation in each developing country is going to be different with different priorities, different diseases and different funding options. The following information is intended to provide those seeking to improve infection control a starting point for discussion and a platform to move forward.

Importance of Veterinary infection control

Nosocomial or 'hospital acquired infections' are infections acquired in hospitals by patients who were admitted for a reason other than that infection. Hospital acquired infections are estimated to occur in 5-19% of hospitalized human patients worldwide (WHO, 2010). While there are no good studies or published estimates on nosocomial infection rates in veterinary hospitals, there is no reason to believe that the risks are lower in veterinary facilities than in human hospitals. The consequences of disease spread in veterinary facilities can be great--animal illness, suffering, death, human illness, loss of reputation and client confidence, hospital closure, loss of income and increased antibiotic use and increased antibiotic resistance.

The standard is changing, we have an increased level of awareness of the risks and improved ability to diagnose veterinary hospital acquired infections. Veterinary teaching hospitals in particular have the responsibility to educate future veterinarians by demonstrating a commitment to practicing infection control, providing outreach to clients and other members of the public regarding disease prevention. Public knowledge is increasing about infection control matters and with it their expectations of excellence in veterinary care. The veterinary profession must rise to the challenge.

The infection control situation in Veterinary facilities in developing countries like India needs critical attention. India has a vast network of 8,732 veterinary polyclinics and hospitals, 18,830 dispensaries and 25,195 veterinary aid centres (including semen centres and mobile dispensaries) spread across the nation providing support to 11% of the world livestock population (GOI, 2011). Actually as rightly quoted by Swaminathan (2006) in India, agricultural biosecurity covering crops, trees and farm and aquatic animals is of highest importance since it relates to the livelihood security of nearly 70 percent of the population and the food, health and trade security of the country.

Infection control in Veterinary facilities in US

There are no uniform biosecurity requirements, laws or rules that cover all types of veterinary facilities (veterinary teaching hospitals, private veterinary clinics and animal shelters) in the United States.

The American Veterinary Medical Association provides accreditions to veterinary teaching hospitals with general expectations regarding maintaining clean facilities and equipment. The majority (84%) of veterinary teaching hospitals in the US have infection control committees and most (89%) have a written policy on infection control (Benedict, 2008). Studies indicate that 82% of veterinary teaching hospitals have reported an outbreak of nosocomial infection in the past 5 years, with 45% reporting more than one outbreak. Half of the veterinary teaching hospitals report zoonotic infection in staff or clients in the recent past (Benedict, 2008). Pathogens involved in outbreaks in US veterinary teaching hospitals include (in order of occurrence): Salmonellosis, MRSA, E.coli, Campylobacter, Cryptosporidium, Enterococcus, Pseudomonas, Clostridium, Enterobacter, equine influenza, Bordetella, Chlamydophilia, dermatophytes, Listeria and Blastomyces.

Private veterinary clinics also have a wide variety of infection control programs in place usually based on previous experience with infectious disease outbreaks. The American Animal Hospital Association (AAHA) and the National Association of State Public Health Veterinarians (NASPHV), have developed material and guidelines which are very helpful in setting up infection control plans for private veterinary clinics.

Animal shelters are often at greatest risk of infectious disease spread and thus in greatest need of practical guidelines and prevention measures. The level of knowledge of shelter workers and volunteers on infectious disease and infection control measures varies greatly; shelters are in need of training and input in these areas (Steneroden et al., 2011a). Shelter environments can be commonly contaminated with infectious pathogens including salmonella (Steneroden et al., 2011b) and shelter worker training can increase knowledge and awareness of infectious and zoonotic diseases (Steneroden et al., 2011c) to the benefit of shelter animals and workers. National shelter organizations and animal welfare organizations have developed practical information and help for shelters with regard to infection control including the Association of Shelter Veterinarians and Maddies Fund (See resources).

To our knowledge there are no surveillance programs relating to biosecurity in veterinary hospitals in India. Veterinarians working at India institutions from rural institutes to multispecialty teaching hospitals, follow simple means of infection control. The basic constraint is lack of awareness of specific infection control or biosecurity programs. It is not necessary to compare the superiority or inferiority of infection control in developed and developing countries, but it is time to re-think the importance of implementing biosecurity practices, which are more effective in breaking the spread of infection from human to animal, animal to animal and animal to human. Lack of awareness is the major reason behind spread of infectious and zoonotic diseases in India.

Written Infection control plan

Writing an infection control plan should be the first step in implementing good infection control in all types of veterinary facilities.

The initial phase of developing the biosecurity plan should include a veterinary facility walk through to assess the flow of patients, personnel and clients through the hospital. The critical control points for disease transmission and hygiene efforts may include the following: entrance/reception area, exam rooms, kennels, surgery, isolation, laboratory, necropsy, equipment supply and food storage.

The following principles and practices can be used to develop guidelines and to review current protocols

Hand Hygiene

Hands can act as carriers of disease from animal to animal and from animals to humans. Veterinary facilities should strive to place sinks in high use areas and ensure that plenty of soap, towels and hand sanitizers are available in all animal contact areas. Hand sanitizers serve a useful purpose, but do not take the place of thorough hand washing with running water and soap. Using hand sanitizers is inadequate when hands are contaminated with visible dirt or organic debris or in the presence of pathogens such as parvovirus, panleukopenia and calicivirus.

Cleaning and Disinfection

Planning, practice and training is required for veterinary facilities to implement effective cleaning and disinfection protocols.

Cleaning and disinfecting should always be thought of as a 3-step process. Step one is the mechanical removal of visible organic matter. This is the first and most important step in the sanitation process. Most detergents and disinfectants are either completely or to some degree inactivated by the presence of organic material such as food, feces, urine or soil so, removal of visible contamination before cleaning with soap or detergent is essential (Russell and Hugo, 1987). Step 2 involves cleaning with soap or detergent and warm to hot water. Removal of visible waste in step 1, along with thorough cleaning with soap or detergent and hot water in step 2 will remove 90% of environmental pathogens (Morgan and Jones, 1987) and are the most important factors in determining the outcome of disinfection activities (Kahrs, 1995). All surfaces should be rinsed thoroughly after cleaning with soap or detergent. Step 3 is disinfection. Disinfectants must be applied to clean surfaces as many of them are inactivated by the presence of organic matter (food, urine, feces, blood, saliva, etc.) Disinfectants can also be inactivated by the presence of detergent or soap left on a surface through inadequate rinsing during step 2.

Cleaning and disinfection products must always be used at their proper concentrations. Accurate measurement with measuring devices (cups) is necessary to ensure proper concentration (Coppock et al., 1988; Bello et al., 2009). Disinfectant products should never be mixed together unless specifically approved by the manufacturer. For instance, soaps and detergents inactivate quaternary ammonium compounds (Jeffrey, 1995) and mixing bleach with ammonia can result in toxic vapors. Certain cleaning products should be used with caution or not at all in animal facilities. Phenolic compounds such as Lysol and Pinesol should be avoided in facilities that care for cats, as they are highly sensitive to these products (Petersen et al., 2008). Consult the disinfectant label and manufacturer's instructions carefully for information regarding preparation, shelf life after preparation, storage, application, safety and post-application rinsing instructions.

A written cleaning and disinfection plan should list the item or area to be cleaned and disinfected, the frequency of sanitation, along with the staff member who will be responsible for completion of the tasks. A step-by-step guide to carry out the cleaning and disinfection procedures should walk the employee through the expected process and they should be made aware of potential hazards to themselves, the animals and the environment with regard to the use of specific chemicals and products (Grow, 1995). It is also important to include information on the use of personal protection for those who are involved in cleaning and disinfection i.e. the appropriate use of gloves, masks or goggles when mixing and using chemicals (Grow, 1995; Kahrs, 1995).

Items and areas a cleaning and disinfection plan should consider addressing include kennels, cages, dog runs, aisles and hallways, animal carriers, food and water dishes, litter pans, toys, bedding, offices including door knobs, computers and computer keyboards, telephones and office equipment, other indoor animal areas such as grooming rooms, treatment rooms, intake, visiting rooms, exercise yards, animal transport vehicles, work clothing (uniforms, boots), tools such as mops squeegees and pooper scoopers, ventilation and heating ducts and storage areas. Without proper safeguards, the potential exists for the spread of disease by those performing sanitation activities through use of contaminated equipment or contaminated clothing or hands. Separate supplies should be provided for each section of the veterinary facility so that disease in not spread between areas on cleaning equipment such as mops, rags and buckets. Spreading or aerosolizing disease particles during cleaning should be avoided by using damp mops, electrostatic mops or dust mops rather than vigorous cleaning with brooms and high-pressure hoses where animals are present. Staff should change outer clothing and gloves and wash hands before going to different areas and after cleaning. Wearing designated clothing for cleaning that can be changed before handling animals will help to reduce the possibility of disease spread.

Environmental contamination

Some pathogens cause widespread and persistent environmental contamination in veterinary facilities (Steneroden et al., 2011b, Steneroden et al., 2011c). Non-porous surfaces such as stainless steel are much easier to clean and disinfect than unsealed wood, for instance. A facility's type, its age and building materials can contribute to disease persistence in the environment.

Certain pathogens require focused and specific intervention in order to remove them from the environment. Parvovirus, panleukopenia virus, calicivirus, salmonella, parasite eggs and ringworm spores can be especially troublesome; it requires rigorous attention to cleaning and disinfection to remove and inactivate these pathogens. Products used for normal disinfection may not likely be effective against them; bleach or trifectant are more effective for disinfection.

Barrier precautions and Personal Protective Equipment (PPE)

Barrier precautions and PPE vary from a separate outfit worn while performing work duties, to specialized equipment to wear while performing certain high-risk procedures on animals. Designed to protect street clothes from contamination, barrier precautions and PPE should be changed and laundered daily and should not be worn outside of the work environment. Veterinary facilities should provide separate uniforms or clothing for staff to wear or encourage employees to bring separate clothing to during work. In order to prevent the transmission of disease from the veterinary facility to the employee's own pets, clothing and shoes that are worn in the veterinary facility should not be worn home. Guidelines must be developed covering use of gloves and obstetric sleeves, facial protection (masks, face shields) respirators (n-95's, full face PAPR's) protective outerwear (lab coats, smocks, aprons and coveralls), footwear, head covers.

Waste disposal

Disposal of animal waste including pathology waste, obstetric waste, animal carcasses, bedding, sharps and biologics provides a challenge in many veterinary facilities. Medical waste from potentially high-risk infectious or zoonotic pathogens should be handled with extra precautions. Medical waste must be protected from vectors, rodents and other scavengers.

Precautions should be taken to prevent injuries caused by needles, scalpels and other sharp objects. To prevent needle injuries, personnel should avoid recapping needles, purposely bending or breaking needles or removing needles from disposable syringes. Sharps should be placed in a puncture-resistant container for disposal.

Patient contact

In veterinary facilities, patient care usually requires intensive contact with multiple patients throughout the day. It is important to remember that this contact may result in the transmission of infectious and/or zoonotic agents. As a result staff should minimize contact with patients whenever this is possible especially if they are not directly responsible for their care. Those responsible for animal care must wash their hands between patients. Equipment such as stethoscopes, probes and other equipment must be wiped with alcohol or hand sanitizer between patients. When appropriate, patients should be monitored by observation without physical contact. In order to decrease the potential for inadvertent trafficking of infectious agents, personnel should also minimize movements between different service areas such as livestock areas, surgery and small animal patient care areas

Identification and isolation of infectious animals

One of the most important things that can be done to limit the spread of infectious disease is for timely identification and isolation of potentially infectious patients. There must be clear guidelines for identification, transfer, isolation, housing and sanitation of infectious patients.

Animals isolated with a contagious or zoonotic disease should be clearly marked to indicate their status. Only those items and equipment needed for the care and treatment of the patient in the isolation room, including dedicated cleaning supplies should be in the room. Clean and disinfect or discard protective equipment between patients and whenever contaminated by body fluids. Limit access to the isolation room.

Miscellaneous protocols

In order to decrease the likelihood of zoonotic disease spread to humans, employees should only eat, drink and smoke in designated areas of the hospital away from animal care areas.

Employees must be trained in animal restraint including the use of equipment (including bite resistant gloves, muzzles) and sedation or anesthesia used for restraint. Animal owners should be used only when necessary and advised of the risks of bites, kicks and scratches. It is usually best to rely on experienced veterinary personnel rather than owners for animal restraint.

Oversight

Every veterinary facility needs leadership to provide day to day as well as long-term oversight of infection control. In small facilities it may be one person, in larger facilities a team or committee may be more appropriate. Infection control committees in veterinary teaching facilities should be made up of members from different departments such as microbiology, epidemiology, clinical medicine (small animal and livestock), pathology those involved in cleaning and disinfection, animal nursing staff and those involved in patient care. The committee should meet periodically to write up infection control policies, review infection control problems, determine research issues, training needs, and to provide day to day infection control leadership for the hospital.

Training

The cornerstone of all infection control strategies is education and training. Improvements in infection control require the leadership at veterinary practices to make disease prevention a priority and integrate infection control practices into everyday practice.

Faculty and staff training should occur upon hire and occur at least yearly. Infection control is an inconvenience to personnel; they must be educated on the risks, potential hazards and benefits of infection control. Training should emphasize infection control practices, the recognition of signs of infectious diseases with their routes of transmission, the potential for zoonotic disease exposure, hazards associated with animal work duties, injury prevention and instruction in animal handling and restraint. Training can occur through classroom instruction, handouts, online modules, shado-wing (following senior staff or faculty while doing their infection control activities) and attendance at conferences. Faculty and senior staff must act as role models. Having people in senior positions demonstrating appropriate infection control practices sets a powerful example for others. The teaching of infection control is a continuous process and to provide the most effective training it must be re-evaluated and revised to keep pace with new knowledge and new situations.

Surveillance and Monitoring Systems

Biosecurity requires reliable disease monitoring or surveillance. Disease surveillance is the key to early warning of a change in the health status of any animal population. It is also essential to provide evidence about the absence of diseases or to determine the extent of a disease that is known to be present. The two terms 'surveillance' and 'monitoring' are often used interchangeably in animal health programs. Monitoring by definition lacks any kind of action to prevent or control a health problem. Surveillance, on the other hand, includes an action to prevent or control the health problem. In actual field situations, monitoring usually allows early reaction should surveillance activities indicate introduction or spread of a disease.

One of the main components for any surveillance system is the collection of data, which can be classified as either passive or active. Active data collection refers to the systematic or regular recording of cases of a designated disease or a group of diseases for a specific goal of a monitoring or surveillance system. A population by specific location and/or time period is usually defined for the system. This should provide each individual within the defined population with a known and often equal chance of being selected. The identification of such an appropriate population depends on the event of interest, its expected prevalence and the available diagnostic tests. Data about the health-related event might be collected from owners during the admission of patients. Biological samples might be collected during the admission and/or during hospitalization. In addition, the screening of animal medical records, either the files or electronic databases, for specific entries, or biological sample banks for specific pathogens or lesions, can be considered part of the active collection of data for surveillance.

Passive collection of data involves the reporting of clinical or subclinical suspect cases to the hospital authorities by the hospital clinicians and others at their discretion (Lilienfeld and Stolley 1994). The validity of the system depends solely on the willingness of these professionals to secure the flow of data. The passive collection of data can be influenced by the awareness and level of knowledge of a particular disease among clinicians or owners of animals. Another important component for this type of data collection is the availability of a diagnostic laboratory scheme to support and confirm cases. The main limitation of passive data collection is inconsistency in the data collection for different diseases and among communities that provide the data. Passive collection of data for surveillance system can identify a change in a pattern that may warrant further investigation. Typically then an active method of collection of data can be implemented.

Zoonotic disease risks

Zoonotic diseases risks vary depending on geographical locations. If there are zoonotic diseases that are endemic in your area or of special concern, specific disease protocols should be written to address these diseases.

Brucellosis is a good example of an important zoonotic disease risk in India for which biosecurity programs and client outreach should be developed. Dairy products prepared from unpasteurized milk may contain high concentration of the bacteria and consumption of these is an important cause of brucellosis in the general population in India. Consuming fresh goat's milk combined with herbal extracts to obtain relief from chronic ailments is reported to be one more risky habit in Indian population. Skinning stillborn lambs and kids and aborted fetuses, which may be heavily contaminated with Brucella spp., also presents a high risk of brucellosis (Awad 1998). Contamination of skin wounds may be a problem for persons working in slaughter houses or meat packing plants and for veterinarians. Inhalation is often responsible for a signifi cant percentage of cases in abattoir employees. (Robson et al., 1993). Brucellosis has been recognized as one of the common laboratory transmitted infections and has been reported to occur in clinical, research and production laboratories (Bouza et al., 2005).

Veterinarians and laboratory workers, working with cattle, sheep and goats in all types of facilities must be aware of the modes of brucellosis transmission and must institute biosecurity practices and protoccols to protect themselves and their clients. The awareness of the general public to the risks of brucellosis can be raised through direct communication as well as posters and materials for distribution.

Biosecurity an infection control are important considerations for veterinarians in all types of practices in developed and developing countries. Biosecurity begins with awareness and the commitment of individuals to instituting an infection control plan, providing oversight and finally to education not only of veterinary workers but also to clients and the general public in order to raise the level of health for all.

Resources

Colorado State University Biosecurity SOP. http:// csuvets.colostate.edu/biosecurity/

National Association of State Public Health Veterinarians. Veterinary Standard Precaution Compendium and Model Infection Control Plan for Veterinary Practices. http://www.nasphv.org/documents Compendia.html.

Iowa State University-Center for Food Security and Public Health. http://www.cfsph.iastate.edu/ Infection_Control/overview-of-infection-control-forveterinarians.php.

American Animal Hospital Association. Assessed 21 April 2012 at https://www. aahanet. org/default.aspx.

Maddies Infection Control Manual for Shelters Assessed 21 April 2012, available at: http://www.cfsph.iastate.edu/ products/maddies-infection-control-manual-for-animalshelters.php

Miller, L., S. Zawistowski, Eds. (2004). Shelter Medicine for Veterinarians and Staff. Ames, Iowa, Blackwell Publishing.

Miller, L., Hurley K Eds. (2009). Infectious Disease Management in Animal Shelters. Ames, Iowa, WileyBlackwell.

Association of Shelter Veterinarians Shelter Guidelines. Accessed 21 April 2012 at http://www.sheltervet.org.

References

Awad, R. (1998). Human brucellosis in the Gaza Strip, Palestine; East Mediterr. Health J. 4: 225-33.

Bello, A., M. Quinn, M. Perry and D. Milton (2009). Characterization of occupational exposures to cleaning products used for common cleaning tasks-a pilot study of hospital cleaners. Environmental Health 8:11.

Benedict, K., Morley, P. and Van Metre, D. (2008). Characteristics of biosecurity and infection control programs at veterinary teaching hospitals. J Am. Vet. Med. Assoc. 233:767-73.

Bouza, E., Sanchez-Carrillo, C., Hernangomez, S. and Gonzalez, M.J. (2005). Laboratory-acquired brucellosis: a Spanish national survey. J. Hosp. Infect. 61:80-83.

Coppock, R. W., Mostrom, M. S. and Lillie, L. E. (1988). The toxicology of detergents, bleaches, antiseptics and disinfectants in small animals. Vet. Hum. Toxicol. 30:463-73.

GOI (2011). Annual Report, Department of Animal Husbandry, Dairying and Fisheries, Ministry of Agriculture, Government of India, New Delhi.

Grow, A.G. (1995). Writing guidelines to require disinfection. Revue Scientifique Et Technique 14: 469-77.

Jeffrey, D. J. (1995). Chemicals used as disinfectants: active ingredients and enhancing additives. Revue Scientifique Et Technique 14: 57-74

Kahrs, R.F. (1995). General Disinfection Guidelines. Revue Scientifique Et Technique 14:105-22.

Lilienfeld, D.E. and Stolley P.D. (Eds.) (1994). Foundations of Epidemiology, 3rd Edn., New York, Oxford: Oxford University Press.

Morgan Jones, S. (1987). Practical aspects of disinfection and infection control. Disinfection in Veterinary and Farm Animal Practice. Linton A.H., Hugo W. B. and Russell A.D. Oxford. Blackwell Scientific Publications 144-167.

Petersen, C., G. Dvorak, A. Spickler, Eds. (2008). Maddie's Infection Control Manual for Animal Shelters. Ames, Iowa, Center for Food Security and Public Health.

Robson, J. M., Harrison, M. W., Wood, R. N., Tilse, M. H., McKayA B and Brodribb, T.R. (1993). Brucellosis: re-emergence andchanging epidemiology in Queensland. Med. J. Aust. 159:153-58.

Russell, A. D., Hugo, W. B. (1987). Chemical disinfectants. Disinfection in Veterinary and Farm Animal Practice. Linton A.H., Hugo W. B. and R. A. D. Oxford, Blackwell Scientific Publications: 12-42.

Steneroden, K., Hill, A. and Salman, M.D. (2011a). A needs assessment and demographic survey of infection control and disease awareness in western US animal shelters. Prev. Vet. Med 98:52-57.

Steneroden, K., Hill, A. and Salman, M.D. (2011b). Environmental sampling for Salmonella spp. in Colorado animal shelters. Zoonoses and Public Health 58:407-15.

Steneroden, K., Hill, A., Salman, M.D. (2011c). Zoonotic disease awareness in animal shelter workers and volunteers and the effect of training. Zoonoses Public Health 58:449-53.

Swaminathan, M.S. (2006). Towards biosecurity in Agriculture. The Hindu, March 31.

WHO (2010). The Burden of Health Care Associated Infection Worldwide A Summary. Accessed 20 April 2012 at http://www.who.int/gpsc/country_work/ summary_20100430_en.pdf

Katie Steneroden (1), M.D. Salman (2), K. Satish Kumar (3), Nitin Bhatia (4) Sangeeta Rao (5)

Animal Population Health Institute

College of Veterinary Medicine and Biomedical Sciences

Colorado State University

Fort Collins, Colorado-80523 (USA)

(1.) Research Collaborator, Veterinary Public Health Specialist

(2.) Professor of Veterinary Epidemiology

(3.) Assistant Professor, Department of Veterinary Clinical Medicine, College of Veterinary Science, SVVU, Hyderabad, Andhra Pradesh

(4.) Technical Services, Intas Animal Health

(5.) Research Scientist, Epidemiology and Biostatistics
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Author:Steneroden, Katie; Salman, M.D.; Kumar, K. Satish; Bhatia, Nitin; Rao, Sangeeta
Publication:Intas Polivet
Article Type:Report
Geographic Code:9INDI
Date:Jan 1, 2012
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