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BMC Emergency Medicine Clinical Practice Guidelines Algorithm

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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) Barbary Macaque Assamese macaque Assamese macaque Barbary Macaque ( Barbary "ape" or (Macaca assamensis) (Macaca assamensis) (Macaca sylvanus) Barbary Macaque ) Celebes "ape", Sulawesi Booted or Sulawesi- Bonnet Macaque Bonnet Macaque Black "ape", or Sulawesi- Booted Macaque (Macaca radiata) (Macaca radiata) Crested Macaque (Macaca ochreata) (Macaca Nigra) 4 Formosan Rock Macaque Japanese Snow Macaque Japanese Macaque Japanese Macaque or Taiwan Macaque (Macaca Fuscata) (Macaca Fuscata) (Macaca Fuscata) (Macaca cyclopis) Cynomolgus monkey, Crab- Eating Macaque, Long- Lion-tailed Macaque Pigtailed Macaque Rhesus Macaque Tailed Macaque, or Java (Macaca silenus) (Macaca nemestrina) (Macaca mulatta) Macaque (Macaca fascicularis) Tibetan Macaque Tonkean Macaque Tonkean Macaque Toque Macaque (Macaca thibetana) (Macaca tonkeana) (Macaca tonkeana) (Macaca sinica) 5 SIMIAN HERPES B VIRUS (Cercopithecine herpes virus 1) BMC Emergency Medicine • Endemic in Macaque Monkeys (rhesus. Pig-tailed, bonnet, cynomolgus) Clinical Practice Guideline ALL MACAQUES MUST BE ASSUMED TO BE VIRUS + • 70% case fatality rate when transmitted to humans • Transmitted through open skin and mucocutaneous exposures (bites, SIMIAN HERPES B scratches, needlesticks, splashes over mucus membranes, open skin) • Biomedical lab workers, animal handlers at risk (live monkeys, monkey VIRUS EXPOSURE tissue cultures, body fluid exposures – blood, secretions, excretions) This guideline is to be used to assist in clinical efficiency, but is • 2days – 5weeks incubation period, but latent presentations occur not a substitute for clinical • Disease In Humans: Early-Skin vesicular eruptions, ulcerations; regional judgment 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 PRIMATE EXPOSURE genital secretions, nervous system tissue, or material contaminated by macaques. - POSSIBLE SIMIAN HERPES B VIRUS EXPOSURE REFER TO OCCUPATIONAL & ENVIRONMENTAL YES MEDICINE Monday – Friday Non-Holiday TO BE INTERVIEWED 7:30 am – 4:00 pm BPHC Lab reporting regulations applies to B IMMEDIATELY Virus. Report exposures, illnesses, or BMC OEM absenteeism to Occupational Health Officer 732 HARRISON AVE at (617) 353-6630 or (617) 780-5519 (cell) or BOSTON, MA 02118 (617) 638-8400 Herpes B Virus Prophylaxis OEM. Complete the BPHC Research Recommended Laboratory Reporting Form found at: 1. Skin exposure or mucosal exposure (with http://www.bphc.org/bphc/pdfs/LabReportCa or without injury, i.e. eye) to a high-risk rd.pdf source NO 2. Inadequately cleaned skin exposure or mucosal exposure 1. Wound care – cleanse & 3. Laceration of head, neck, or torso. irrigate with detergent for 15 Refer to Boston Medical 4. Deep puncture bite Center 5. Needlestick associated with tissue or minutes; debride only if necessary. fluid from the nervous system, lesions 2. Eye flush/irrigation for 15 min. EMERGENCY suspicious for B virus, eyelids, or mucosa 3. Valacyclovir, 1 g po q8h for 14 DEPARTMENT 6. Puncture or laceration after exposure to days* MENINO PAVILION objects (a) contaminated either fluid from 4. Culture – debrided tissue monkey oral or genital lesions or with should be placed in viral transport (617) 414-7759 nervous system tissues, or (b) known to media and sent for B-virus cx; contain B virus. Patients Must Be Evaluated swab wound for viral cx as well. 7. A post cleaning culture is positive for B at 5. Start Abx – Augmentin or virus OCCUPATIONAL & Keflex for bites. ENVIRONMENTAL 6. Td as indicated (booster if bite MEDICINE and Td > 5 yrs ago) Next Business Day 7. Acute serum collection (aliquot and preserve at –20ºC or lower and Herpes B Virus Prophylaxis Considered 732 Harrison Avenue 1. Mucosal splash that has been adequately send to micro lab, complete forms Boston, MA 02118 cleaned for B virus lab. (617) 638-8400 2. Laceration (with loss of skin integrity) 8. Provide patient information in that has been adequately cleaned first aid packet and schedule OEM ANY PATIENT 3. Needlestick involving blood from an ill or follow-up appointment. PRESENTING WITH immunocomprimised macaque Puncture or laceration occurring after SYMPTOMS OF B VIRUS exposure to (a) objects contaminated with SHOULD BE ADMITTED body fluid (other than that from a lesion), or FOR IV GANCICLOVIR (b) potentially infected cell culture CONSULT ID SERVICE Herpes B Prophylaxis Not Recommended EMERGENCY CONSULTATION 1. Skin exposure in which the skin remains If an exposed person exhibits any of these intact symptoms please contact Julia Hilliard, Ph.D. at 2. Exposure associated with non-macaque the National B Virus Resource Center at species of nonhuman primates 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
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