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

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) VIRUS EXPOSURE • Biomedical lab workers, animal handlers at risk (live monkeys, monkey 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 exposed carefully for evidence that an exposure has occurred

Consider obtaining serum samples at baseline for serologic analysis

Consider culturing specimens from the site of the wound or the exposed mucosa

Do not culture wound before cleaning. This is contraindicated as it may further contaminate the wound.

Nonhuman primate

Examine the animal for mucosal lesions (e.g., vesicles, ulcers), conjunctivitis, etc.

Consider culturing specimens from the lesions, conjunctiva, and buccal mucosa

Consider serologic testing for B virus (if the animal is not known to be seropositive)

Education and Treatment

Counsel the patient regarding the significance of the injury

Ensure that the patient's occupational health care provider and supervisor are notified of injury

Review with the patient and his or her work supervisor the safety precautions in place at the time of injury

Schedule a follow-up appointment

Determine if tetanus or prophylactic treatment with antibiotics is indicated

Consider postexposure prophylaxis for B virus below

Patient Education and Follow-up is included in the first aid information pack: Provide the patient with all the information in the package that has First Aid on the cover.

8 1. Review information on the signs and symptoms of B virus infection in packet.

2. Ensure that the patient has a card (to carry in his or her wallet) that includes information on B virus and a phone number to call for advice in an emergency.

3. Patients should be counseled regarding transmission of B virus to others after an exposure by body fluids or skin lesion contact.

4. Provide the patient with information on B virus symptoms, emergency contact card with B virus emergency contact information, and referral to Occupational Health on the next business day, tel: (617) 638-8400, (If seen in the Emergency Department).

INSTRUCTIONS FOR CLINIC AND EMERGENCY DEPARTMENT STAFF

Bite, Scratch, Mucous Membrane Exposure or Contaminated Needle Stick, Scalpel or Cage Injury

Assess the adequacy of wound cleansing and repeat 15 minutes more of cleansing as described in previous section.

Splash to the eye: This should rarely occur because employees should be wearing face shields and safety glasses with side shields, or goggles with a surgical mask. If the employee is exposed to contaminated secretions, then, following the immediate cleansing of the eye for 15 minutes, a culture from the eye and serology studies should be done as outlined above. Repeat 15 more minutes of eye wash in ED or Clinic

Evaluate the need for debridement and prophylactic antibiotics, e.g., Augmentin (drug of choice) or cephalosporin, to prevent bacterial infection.

Collect a viral culture from the wound or exposure site after washing and disinfecting. (Use Viral Transport Media and sterile cotton or polyester "Dacron" swabs.)

Collect baseline blood specimen for antibody titers to B virus. (The paired serum will be collected at three weeks from exposure at the BMC Occupational & Environmental Medicine Clinic, on F5, phone (617) 638-8400.

Document adequacy of wound cleaning, record mechanism of injury, likelihood of wound contamination, effectiveness of wound cleaning, tetanus status, and general evaluation of patient’s health (medication use, allergy to medications and baseline medical conditions).

Document examination of wound and overall physical examination sufficient to provide comparison if patient condition changes (dermatologic, ocular, respiratory, cardiovascular, lymph nodes, and neurologic examinations.

9 Counsel the patient on symptoms to watch for and precautions to take at home while awaiting results of cultures and blood tests. (Normally, viral cultures are reported as negative in one week and serology results should be reported in two to three weeks. Until then the CDC guidelines recommend that, "It is prudent for persons who have had high-risk exposures to avoid activities involving the exchange of body fluids (including saliva) until tests of sera have shown no evidence of seroconversion."

Ensure proper storage of specimens prior to shipment. (If held longer than two hours, viral serum specimens should be frozen. See Sample Collection and Handling Forms Below.)

Notify the Microbiology Laboratory at East Newton Campus 617-638-7890 and tube the specimens to pneumatic tube station #2. Make sure the correct B Virus forms are filled out. Initial serum specimen needs to be frozen as instructed on form and sent out with paired specimen two weeks later.

Virology and blood samples from the involved monkey will be the responsibility of the company veterinarian.

Refer the patient to follow-up on next business day to BMC Occupational and Environmental Medicine, tel: 617-638-8400.

Provide the patient with Dr. Hilliard’s (NIH B-virus laboratory) tel: (404-651-0808). Emergency: Dr. Julia Hilliard, Director: 404-358-8168 for emergency and a list of symptoms of concern below (in packet labeled first aid).

Notify attending veterinarian. To date all macaque monkeys that have been tested have been positive serologically for B-virus. Leave message at 617-638-4086.

All information necessary to provide to exposed employee is prepared for the employee in the Employee First Aid Postexposure Prophylaxis Instructions for B Virus and Employee Training Packet.

EVALUATION OF POST EXPOSURE PROPHYLAXIS FOR B VIRUS EXPOSURE

Exposures Include: macaque bites; macaque scratches; or contact with ocular, oral, or genital secretions, nervous system tissue, or material contaminated by macaques (e.g., cages or equipment) (see the Postexposure Prophylaxis section of the text for details).

Prophylaxis Recommended

___ Skin exposure (with loss of skin integrity) from a high-risk source ___ Mucosal exposure (with or without injury) from a high-risk source (e.g., a macaque that is ill, immunocompromised, or known to be shedding virus or that has lesions compatible with B virus disease). ___ Inadequately cleaned skin exposure (with loss of skin integrity) or mucosal exposure (with or without injury) ___ Laceration of the head, neck, or torso ___ Deep puncture bite

___ Puncture or laceration after exposure to objects (a) contaminated either with fluid from monkey oral or genital lesions or with nervous system tissues, or (b) known to contain B virus ___ A postcleansing culture is positive for B virus

Prophylaxis Considered

___ Mucosal splash that has been adequately cleaned ___ Laceration (with loss of skin integrity) that has been adequately cleaned ___ Needlestick involving blood from an ill or immunocompromised macaque ___ Puncture or laceration occurring after exposure to (a) objects contaminated with body fluid (other than that from a lesion), or (b) potentially infected cell culture

Prophylaxis Not Recommended

The only situations that prophylaxis is not recommended is those exposures in which the skin remains intact, or exposures associated with non-macaque species of nonhuman primates.

PROPHYLAXIS for exposure to B virus (See PDR for specific prescribing information)

Drug of first choice: Valacyclovir, 1 g po q8h for 14 days;

Alternative drug: Acyclovir 800 mg po 5 times per day for 14 days (consider if pregnant as drug of choice)

Draw initial serum at time of injury and convalescent serum at 2 weeks and 4 weeks after discontinuation of prophylaxis or if there are any symptoms of B virus in those potentially exposed at anytime.

11 B Virus Symptoms

Inform patient to contact clinic immediately or emergency department at BMC if any symptoms potentially related to B-Virus occur. Remind employee to continue to be aware of these symptoms for the next several weeks. (See below)

Symptoms that Could Be Related to a B Virus Infection

For an employee who reports symptoms that could be related to a B virus infection, the protocol depends upon the exposure history. If the worker gives no history of exposure and the signs or symptoms are not specific to a herpesvirus infection, e.g., a flu-like illness, then the physician should consider simply observing the patient. Further assurance could be obtained by drawing blood for serology studies. Check with the B Virus Laboratory to see if they recommend doing studies on a "stat" basis.

If the risk of infection appears to be higher, either because of the history of a recent exposure or because of symptoms specific for a B virus infection, then hospitalization and intravenous antiviral therapy should be considered. When setting up the prevention program, a local hospital-based physician, knowledgeable in the treatment of B virus, should be designated as the consultant for the clinic.

For consultation by phone: 404.651.0808 Emergency: Dr. Julia Hilliard, Director of the NIH B Virus Lab: 404.358-8168

Clinical manifestations suggesting active infection with B virus.

Early manifestations (inconsistently present) 1. Vesicular eruptions or ulcerations at or near the exposure site 2. Severe pain or itching at the exposure site 3. Regional lymphadenopathy Intermediate manifestations (inconsistently present) 1. Fever 2. Numbness, paresthesia, or other neuresthesias at or near the exposure site, with or without proximal progression. 3. Muscle weakness or paralysis in the exposed extremity 4. Conjunctivitis 5. Persistent hiccups Late manifestations (avoidable with early therapy) 1. Sinusitis 2. Neck stiffness 3. Headache lasting > 24 hours 4. Nausea and vomiting 5. Brain-stem findings: diplopia, dysarthria, dysphagia, dizziness, cross hemiparesis, cerebellar signs with ataxia, crossed sensory loss, cranial nerve palsies, or drop attacks 6. Altered mentation 7. Other signs compatible with CNS impairment or viral encephalitis including urinary retention, respiratory failure, convulsions, twitching, hemiparesis, hemiplegia, other localized neurological signs, progressive ascending paralysis, or coma

TREATMENT OF B-VIRUS INFECTION

Standard precautions: Should be used in taking care of patients undergoing treatment for B virus.

Any signs or symptoms of B virus disease or positive culture (not post-cleansing culture) start treatment:

• Contact ID attending and Contact B-virus Laboratory (404.651.0808) • Take detailed history and physical examination, documenting skin lesions and neurological status.

Laboratory Studies:

• Culture lesions, conjunctiva, oropharynx, for B virus, serological testing for B virus using appropriate Viral Transport Media and cotton or dacron swabs. • CBC with differential, pregnancy test, Lumbar puncture, MRI of the brain, EEG to differentiate herpes simplex viral encephalitis, consider brain stem auditory evoked potential

Treatment:

Most experts believe that therapy should be switched to oral valacyclovir, famciclovir, or acyclovir at the dosage used for post-exposure prophylaxis. Repeated cultures of the conjunctivae and oral mucosa weekly during the first few weeks of discontinuation of therapy is recommended. If neurological symptoms develop at any time, cultures for B virus should be obtained.

OCCUPATIONAL HEALTH FOLLOW-UP CLINIC VISITS FOR B-VIRUS EXPOSURES

Include patient name, date and time of visit. Date of initial exposure. Week since initial exposure. Contact information including cell phone, work phone, home phone. ID#, immediate supervisor and supervisor phone number.

You must contact any patient that misses a B-virus F/U appointment.

13 Week 1 Follow-up visit in OEM:

1) Make sure serum was sent to the BMC microbiology lab. 2) If baseline serum not drawn get baseline serum and send to BMC microbiology lab to send out with paired specimen to be drawn end of week 2 or beginning of week 3. Only paired serum will be sent to B virus laboratory. See information on collection of cultures and serum in this packet. 3) If employee was seen in the Emergency Department get record. 4) Review need for prophylactic antibiotics, and tetanus booster. [After a bite, booster should be given if the last tetanus is greater than 5 years ago]. 5) Review decision for antiviral prophylaxis for B virus. Exposure and prophylaxis]. (See p. 9-10) 6) Contact vet regarding health status of NHP. 7) Evaluate wound if a bite. (Look for vesicles or redness, swelling, or other signs of infection. 8) Evaluate patient for symptoms of B virus using the checklist below. Evaluate for skin lesions or mucous membrane lesions at site of injury/bite consistent with herpetic lesions. 9) Perform serological testing if there is a change in clinical status. 10) Assess compliance with treatment if prophylaxis has been prescribed at each visit. Any symptoms consistent with B virus contact physician in charge, Infectious disease attending on call and B virus laboratory (emergency number after hours. See below for initial instructions for evaluating and treating B virus disease. 11) Provide patient with information on B virus in (First Aid, Postexposure Prophylaxis and training document. 12) Provide patient with a Medical Alert Wallet Card to carry, if not provided in ED.

Serological Testing

1) On day of exposure confirm or draw a baseline serum 2) Follow-up serum on week 2or 3 for all exposures from date of exposure. 3) If on PEP follow-up with patient weekly in person. Perform Serologic testing at week 2 or 3, and 4 weeks after cessation of prophylaxis medication (about week 6) and at 12 weeks if there are any concerns as to the exposed individual’s health status. 4) Serologic testing should be performed anytime there is a change in clinical status and 4 weeks after discontinuing prophylaxis for those on PEP. This also applies to patients not on prophylaxis and present with symptoms. Anyone who presents with possible symptoms and has potential for exposure needs additional evaluation by a physician and the provider should consult with B virus laboratory.

Additional Follow-up

Include repeat steps 6 – 11, and Serologic testing if indicated as outlined above. 14 REPORT OF INJURY INVOLVING A NONHUMAN PRIMATE BODY FLUIDS

EMPLOYEE STUDENT OTHER

AFFILIATION: BUSM GSDM OTHER

Name: ______

SS#: ______Work Location: ______

ID: ______

Occupation: ______

Tel: ______Supervisor:______

HISTORY

Date of Report: ______Time of Report: ______

Date of Injury: ______Time of Injury: ______

Location of Injury (Bldg., Floor, Room): ______

Safety Measures Employed at Time of Exposure/Injury

______Gloves, Specify type: ______Sleeves ______Eye Protection, Specify type: ______

______Mask, Specify type:

______Other, Specify type:

Type of Exposure

______Skin Exposure Skin Integrity Broken: ______Yes ______No ______Mucous Membrane Exposure ______Eye(s), Specify: ______R ______L ______Both ______Nose ______Mouth ______Percutaneous Injury ______Bite ______Scratch ______Eye(s) Equipment involved: ______Puncture ______Laceration, Depth ______Length ______Instrument Involved ______If needle, gauge______Hollow bore______15 Type of NHP Fluid Involved

______Saliva (Consider BV – See source labs below) ______Blood (Consider SIV, SRV) ______Other, specify: ______

Circumstances of injury (Include how the injury occurred and the body area involved): ______

First Aid at the Work Site

______Wound cleansed/irrigated Time elapsed from injury to initiation of first aid at the worksite ______Agent(s) utilized: ______Duration ______Other, specify: ______

EMPLOYEE’S LAB STUDIES (Check if Ordered)

______Store Serum ______Ocular BV Culture ______Post-scrub ______Other, explain:

TREATMENT (Check appropriate response(s)). For indications of post-exposure prophylaxis refer to pages 9-10. If patient is potentially pregnant get a pregnancy test.

______None Indicated ______TD Update ______Augmentin ______Antiviral Med. ______Dose ______Time lapsed from the time of injury to initiation of antiviral (B Virus) prophylaxis ______Other, specify: ______Employee declines antiviral medicine offered ______Decision held pending results of source’s and/or employee’s lab studies

INFORMATION PROVIDED (Check Appropriate Response(s)

______B Virus Information Sheet ______Other, describe: ______

16 FOLLOW-UP

______None indicated ______Follow-up serum (convalescent serums) 2 or 3 weeks (14-21days from date of injury), and 6 weeks *additional convalescent serum indicated if exposed was on antiviral medication, or presents with symptom potentially consistent with B Virus. Dates: ______1 week f/u ______2 week f/u, and send paired serums or on week 3 ______3 week f/u ______4 week f/u ______6 week f/u or 1 month after cessation of PEP and send serum to B virus laboratory for second convalescent titer. ______6* week f/u send second convalescent titer if any concerns about exposed persons health status, not on prophylaxis ______12* week f/u if indicated as above.

EH&S NOTIFICATION

______Environmental Health & Safety Notified Name: Date and Time:

SOURCE (Consult Veterinarian at Laboratory Animal Science Center 617-638-4086)

Monkey identification: ______Veterinarian Work Address ______

Species (Check One) ______Rhesus ______Cynomolgus ______Other, specify: ______Known illness(es) ______

Clinical Evidence for Possible Current Herpetic Infection (e.g. mucosal ulceration, crusting, conjunctivitis, etc.) ______No ______Yes, explain: ______

Existing Serologic Testing for B Virus

Result Test Date Testing Facility

______Negative ______Blood ______Not Done ______Not Available

17 NHP’s LAB STUDIES (Check if ordered)

Result Date Ordered Date Received ______Blood ______Ocular BV Culture ______Other Area Cultured ______Buccal BV Culture ______Explain: ______Serum Anti-BV ______Nurse or NP ______Consulting MD: ______

18 Questions for callers reporting an injury involving a nonhuman primate (NHP). Please note that the risk for exposure to B Virus depends upon both the type of NHP and the body fluid involved in the injury.

What type of NHP was involved in the injury?

NHP CONSIDER

Old world monkeys B Virus (e.g. rhesus, cynomolgus (cynos), bonnet, and stump tail)

African green monkey, baboon, sooty mangabey, chimpanzee SIV, (RESP)

Rhesus, cynomolgus, squirrel monkey, langur SIV, (RESP)

Which NHP body fluid or tissue was involved in the injury?

NHP FLUID OR TISSUE CONSIDER

Saliva, ocular or genital fluid, neurologic tissue, CSF B Virus

Unknown (e.g. NHP scratch, cage related scratch) B Virus

Blood or bloody fluids SIV, SRV (RESP)

Urine, non-bloody fluids not mentioned above) Neither B Virus nor SIV, SRV

In what type of research activities was the NHP involved?

Does that constitute a health risk for the injured worker?

First aid related questions. MUCOUS MEMBRANE SKIN

What cleaning agent did you use Saline or water Betadine or Clinidine How did you use it? Irrigate Scrub How long did you use it? 15 minutes 15 minutes

What was your last tetanus booster dose?

MORE THAN 10 YEARS MORE THAN 5 YEARS

Repeat now Repeat now for bite, avulsion and crush injuries, and injuries contaminated with dirt or feces

Signature: ______Print Name: ______19

MACAQUE MONKEY PROGRAM:

POSSIBLE INFECTIOUS AGENTS AND THEIR CONTROL

AGENT WORKERS AT RISK METHOD OF CONTROL COMMENTS B Virus Macaque handlers, See Rules to prevent infection below. Source: macaque monkeys cage cleaners and shedding B virus (similar to necropsy technicians 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 TB skin test every 6-12 months to detect converters; The monkeys are susceptible to others who work in all new employees should have the two step test as TB. Once introduced by a macaque rooms recommended by the CDC; human, the disease can spread quickly through the colony. Measles Macaque handlers and If born after 1/1/57, then a booster (MMR) is This is just a routine others who work in recommended; immunization practice. macaque rooms Hepatitis A Macaque handlers and Personal protective equipment; good hand washing; Hepatitis A vaccine is now a others exposed to fecal offer hepatitis A vaccine; routine immunization for contamination travelers to parts of the world where hepatitis A is endemic. Hepatitis B Macaque handlers Worker training regarding sharps; offer hepatitis B Hepatitis B is now a routine part vaccine; 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 This is just a routine wound sustained if more than 5 years; immunization practice. Bite wound infection Macaque handlers Prevention of bites by using safe handling methods; Also consider debridement of consider treatment with Augmentin after deep bites; any contused and nonviable tissue in the wound. Rabies Macaque handlers Observe animal after bite; if becomes ill, then consider It is unlikely that these testing for rabies and beginning immunization of previously quarantined primates worker; would contract rabies.

RULES TO PREVENT B VIRUS INFECTION IN PRIMATE HANDLERS

1. Know the safe methods for handling monkeys and sharps to prevent injuries.

2. Cleanse wounds thoroughly and without delay.

3. Collect specimens from both worker and monkey after an injury and ship promptly to the NIH B Virus Resource Laboratory.

4. Report all injuries and know the symptoms of B virus infection. The evidence from previous human infections suggests that patients survive if they are treated early before advanced symptoms develop.

5. Provide post-exposure prophylaxis if indicated.

21 INFECTIOUS HAZARDS FROM NONHUMAN PRIMATES

Macaques Baboons Guenons Squirrel Chimpanzees Monkeys Viruses B virus Foamy virus Foamy virus Dengue Foamy virus Foamy virus Pox viruses SIV Yellow fever SIV Simian retrovirus Yellow fever Pox viruses Hepatitis B (Type D) Dengue Yellow fever Molluscum SV40 Dengue contagiosum SIV Hepatitis A Pox viruses Pox viruses Yellow fever Yellow fever Dengue Dengue Ebola Ebola Bacteria Burkholdria Campylobacter spp. Campylobacter spp. Campylobacter spp. Burkholdria pseudomallei Leptospira spp. Leptospira spp. Leptospira spp. pseudomallei Campylobacter spp. Mycobacterium Mycobacterium Mycobacterium Campylobacter spp. Mycobacterium tuberculosis tuberculosis tuberculosis Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium bovis Mycobacterium bovis tuberculosis Mycobacterium bovis Salmonella spp. Salmonella spp. Salmonella spp. Mycobacterium bovis Mycobacterium leprae Shigella spp. Shigella spp. Shigella spp. Mycobacterium (also known to occur Yersinia Yersinia Yersinia leprae in mangabeys) pseudotuberculosis pseudotuberculosis pseudotuberculosis Leptospira spp. Leptospira spp. Yersinia enterocolitica Yersinia enterocolitica Yersinia enterocolitica Salmonella spp. Salmonella spp. Shigella spp. Shigella spp. Yersinia Yersinia pseudotuberculosis pseudotuberculosis Yersinia Yersinia enterocolitica enterocolitica

Metazoan Hymenolepis nana Hymenolepis nana Oesophagostomum Hymenolepis nana Hymenolepis nana Parasites Oesophagostomum Oesophagostomum spp. Trichuris trichuria Oesophagostomum spp. spp. Strongyloides spp. spp. Strongyloides spp. Strongyloides spp. Trichuris spp. Strongyloides spp. Trichuris spp. Trichuris spp. Trichuris spp. Enterobius Enterobius vermicularis vermicularis Protozoan Balantidium coli Balantidium coli Balantidium coli Balantidium coli Balantidium coli Parasites Cryptosporidium spp. Cryptosporidium spp. Cryptosporidium spp. Cryptosporidium spp. Cryptosporidium spp. Entamoeba histolytica Entamoeba histolytica Entamoeba histolytica Entamoeba histolytica Entamoeba Giardia intestinalis Giardia intestinalis Giardia intestinalis Giardia intestinalis histolytica Plasmodium spp. Plasmodium spp. Plasmodium spp. Plasmodium spp. Giardia intestinalis Trypanosoma cruzi Plasmodium spp.

Source: Occupational Health and Safety in the Care and Use of Nonhuman Primates (2003), Institute for Laboratory Animal Research 22

30. Purpose of Testing: 1. Symptomatic, 2. Injury Baseline Testing, 3. Injury Follow-up Testing, 4. Routine, 5. Write a specific reason 31. Type of Injury: 1. Bite, 2. Eye Splash, 3. Animal Scratch, 4. Cage or Equipment Scratch, 5. Needlestick, 6. No Injury, 7. Write a specific reason

28 Description of Common Non-Human Primate Procedures at BUMC and Required Eye/Face Personal Protective Equipment Eye/Face/Mucous Membrane Procedure Alternative, if available Protection safety glasses, face shield and NHP Cage Changing goggles and surgical mask surgical mask NHP dental cleaning goggles and surgical mask n/a NHP Live Animal safety glasses, face shield and Transport or Removal goggles and surgical mask surgical mask to Transport Cage Anesthetized NHP safety glasses, face shield and goggles and surgical mask Animal transport surgical mask Lead surgeon currently wearing Safety Glasses (prescription if prescription eyeglasses with side NHP Surgery on needed) with Surgical Loupes, shields and surgical loupes over the Anesthetized Animal Surgical Mask for Lead Surgeon, All glasses with a surgical mask. using Surgical surgical assistants in room should Alternatively, surgical assistants can Microscope wear goggles and surgical mask wear safety glasses, face shield, and surgical mask

Lead surgeon currently wearing Safety Glasses (prescription if prescription eyeglasses with side NHP Surgery on needed) with Surgical Loupes, shields and surgical loupes over the Anesthetized Animal Surgical Mask for Lead Surgeon, All glasses with a surgical mask. using Surgical Loupes surgical assistants in room should Alternatively, surgical assistants can wear goggles and surgical mask wear safety glasses, face shield, and surgical mask

Tracheal Tube Insertion and Removal safety glasses (prescription if needed), during the beginning goggles and surgical mask face shield and surgical mask and end of NHP Surgery

Completed in Fume Hood by Lead Completed in Fume Hood by Lead Perfusion of NHP at Surgeon: Currently wears Surgeon: Involves slicing of heart Termination Surgery prescription eyeglasses and surgical ventricles, NHP anesthetized loupes and surgical mask Magnetic Resonance Anesthetized animals in sealed Imaging of NHP microisolator cage, safety glasses and n/a Anesthetized Animal surgical mask should be worn

EMPLOYEE BITE AND SCRATCH LOG

Employee Health B Virus Culture Provider Follow-up Date Employee Type of Injury Animal Specimen Sent Received Results Date Contact Initials

Boston Public Health Reporting Requirements Employee/Personnel: Within 1 Business Day

Illness • All personnel and laboratory workers are encouraged to report any illness to their supervisor and occupational health directly if they are ill and working with or near agents covered by this BPHC regulation. • Supervisors should refer any ill worker to the Occupational Health Officer (OHO) or designee for evaluation at Boston Medical Center Occupational & Environmental Medicine located at 732 Harrison Avenue, (F5) or the Emergency Department located at the Menino Pavilion at 771 Albany Street for after hours, weekends and on hospital holidays. • Supervisors are required to report all illnesses, significant exposures, and absenteeism to the OHO at (617) 353-6630, (617) 738-4402, or (617) 780-5519 or designee at (617) 414-8262 or (617) 638-8400. The above conditions are reportable to Boston Public Health Commission (BPHC) by OHO or designee. Significant Exposures • All laboratory workers must report any exposures to their supervisor and occupational health directly. • Workers in laboratories working with agents covered by the BPHC regulations must be evaluated by the OHO or designee prior to return to work if exposure to agents covered by these guidelines occurs. Absenteeism • Worker notifies supervisor of reason for absence from work. • Supervisor contacts the OHO or designee. If employee is febrile or symptomatic he/she will need to be evaluated by the OHO or designee. The employee must contact the OHO on day 1 of illness and be evaluated, depending on the symptoms reported and also prior to returning to work if symptoms are potentially consistent with exposure to agent.

Occupational Health Officer (OHO) or Designee: Within 1 Business Day

Illness • OHO or designee will perform an occupational health assessment for any employee who: (1) has been diagnosed, (2) is exhibiting symptoms, or (3) may have been exposed to a registered agent as defined in this regulation. • OHO or designee shall immediately notify the BPHC of the assessment, but not later than one business day of the assessment. • OHO or designee should evaluate the individual based upon clinical findings and epidemiological risk factors, including specific lab work being conducted, and make appropriate recommendations. • OHO or designee shall report findings of the assessment immediately, but not later than one business day. Significant Exposures • OHO or designee shall report to the BPHC any diagnosis of any disease caused by a high–risk registered agent pursuant to Section V. Part A of the guidelines, and any violation or breach of any laboratory procedures or any other incident which the IBC, Project Director or OHO should reasonably believe was released beyond the work area must be reported within once business day. • OHO or designee must evaluate workers in laboratories working with agents covered by the BPHC regulations if an exposure to agents covered in these guidelines occurs. • OHO or designee must report significant exposures to BPHC within 1 business day. • Follow–up information must be provided to BPHC as requested. • OHO or designee must report to BPHC, if a significantly exposed worker develops illness that could be related to an agent used in the laboratory and covered by these guidelines. • OHO or designee should evaluate the individual based upon clinical findings and epidemiological risk factors, including specific lab work, and make appropriate recommendation. Absenteeism • OHO or designee must evaluate any worker in a laboratory using agents covered by these guidelines who is absent from the workplace due to illness for a period of two or more consecutive workdays. • OHO or designee must contact the ill worker to determine whether illness could be related to an agent covered by these guidelines and used in the laboratory. • OHO or designee must be reported within 1 business day to the BPHC, if illness may be related to an agent covered by these guidelines.

Occupational Health Officer (OHO) or Designee: Within 3 Business Days

Illness • If the OHO or designee determines that the illness is caused by an agent that is covered by these guidelines and may be work–related, BPHC must be consulted within 3 business days before the worker is allowed to return to work. Significant Exposures • OHO or designee must send BPHC documentation that an exposed employee was cleared to return to work within 3 business days of clearance.