1. Infection Prevention & Risk Management in a Healthcare Setting
Julie Meyer-Manager of Infection Prevention
Megan Cooper-Patient Relation Specialist

2. Objectives: Describe zoonotic definitions
Identify the difference between service and companion animals

3. Animals-Pets
Over centuries, animals have been domesticated by people who brought these animals into the home environment to share food and shelter.
These animals are what we think of as ‘pets’.
Nearly 1/3 of households in the United States have dogs and cats.
Many people live with less traditional pets, including reptiles, rodents, exotic birds and chickens.
These unusual pets pose different risks to human health and may require additional precautions.
Information about how to handle non-traditional pets can be found on CDC website.

4. Can Animals Cause Infection in the Hospital?
Zoonoses refer to diseases that pass between people and animals.
Recently, researchers have determined that >70% of emerging infectious diseases in people actually come from animals.
Examples of new emerging infectious diseases:
viral hemorrhagic fevers, like Ebola
respiratory diseases, like SARS
What these serious diseases have in common is that they all start as zoonoses in the animal kingdom.
Some of these diseases start in wildlife in remote areas of the world.
Diseases can move around the globe quickly because people and products, such as animals and food supplies, are constantly crossing borders.
Ebola-person infected by a bat
SARS-civet, is a mammal with a catlike body, long legs, a long tail, and a masked face resembling a raccoon or weasel.
While we care for patients that are hospitalized due to illness, we can’t ignore the fact that there are infections that originate from animals.

5. What are the zoonoses that can be transmitted to people by contact with cats and dogs?
Zoonoses that pass directly from dogs and cats to people:
Infect through animal bites or scratches
bacteria like Bartonella that cause cat scratch fever
viruses that cause rabies
diseases like ringworm that are caused by fungi
Infect through Vector-transmitted
fleas, ticks, flies, mosquitoes
diseases for which cats and dogs may act as reservoirs for the pathogen
Diseases transmitted from animal feces when parasite eggs are inadvertently eaten by humans, such as
Roundworms, toxoplasmosis, coccidia, salmonella

6. Reverse Zoonoses
Reverse zoonoses are diseases that do not normally occur in dogs and cats but can be passed from infected people to their pets
e.g. tuberculosis, MRSA, flu

7. Infectious disease
Cats
Dogs
Fish
Birds
Rabbits
Reptiles§
Primates
Rodents§
Campylobacteriosis +
n/a
Capnocytophaga canimorsus infection
Cat scratch disease (Bartonella henselae)
Leptospirosis
Mycobacteriosis
Pasteurellosis
Plague
Psittacosis
Q fever (Coxiella burnetti)
Rat bite fever (Spirrillum minus, Streptobacillus monliformis)
Salmonellosis
Tularemia
Yersiniosis

8. What is the public health role in dealing with zoonotic infections pets?
Local, state, and national public health officials seek to prevent human disease, and that includes zoonotic diseases.
Ex: a child hospitalized because of Brucella canis, a bacteria seen in dogs.
When the child’s laboratory result was communicated to public health officials:
Interviewed the family and determined that a puppy had recently been purchased from a pet store.

9. Is there any kind of surveillance system that monitors zoonotic diseases and infections in pets?
There is no organized surveillance system that counts the number or types of zoonotic diseases occurring in pets.
Sick animals are often treated by independent veterinary clinics.
Information regarding the diagnosis of a fairly minor zoonoses is unlikely to be reported to any kind of surveillance system.
When veterinarians see an increase in the number of animals that come into a clinic with a zoonotic disease, it’s likely that the information will be communicated through informal networks.

10. Zoonotic Disease Studies:
There have been very few studies on whether animals in hospitals can transmit diseases.
In 2006
a study of 100 dogs in hospitals in Ontario
found that about 80 percent of those animals carried potentially harmful bacteria, including Clostridium difficile and Salmonella.
However, the study did not look at whether the animals could transmit the diseases to patients
In the United States, the Centers for Disease Control and Prevention has never received a report of an infection related to pet therapy

11. Pets in the Hospital Are pets allowed?
Should all pets be allowed into a patient's room? 
Should only pets with proven immunization records by allowed entry? 
Should size be a factor? 
This guidance on animals in healthcare facilities has been endorsed by the Association for Professionals in Infection Control and Epidemiology (APIC), the leading professional association for infection preventionists with more than 15,000 members.
Not to confuse pets with service animals as they play different roles.
Some hospitals may balk at the thought of allowing entry of pets into the hospital. 
Many hospitals offer animal therapy with designated dogs and their trained volunteers. 

12. Terms and Definitions Service Animal Companion or Assistance Animal
Animal-Assisted Therapy
Animal-Assisted Activities
Service Animal = a dog (or miniature horse) that has been individually trained to perform a specific task or service for a person with a disability.
Companion or Assistance Animal = animals that help a person with a disability alleviate one or more symptoms of their disability while in their home.
Animal-Assisted Therapy = the planned inclusion of an animal in a patient’s treatment plan.
Animal-Assisted Activities = the use of animals in recreational and visitation programs to help people with special needs.

13. Therapy Dog vs. Service Dog

14. Service Animals A service animal
is not considered a pet
is an animal trained to provide assistance to a person because of a disability.
Title III of the “Americans with Disabilities Act” (ADA) of 1990 mandates that persons with disabilities accompanied by service animals be allowed:
Access with their service animals into places of public accommodation, including restaurants, public transportation, schools, and health-care facilities.
In health-care facilities, a person with a disability requiring a service animal may be an employee, a visitor, or a patient.

15. Service Animals
There are 2 questions staff can and should ask when an animal enters the healthcare setting-
Is this animal required because of a disability?
What work or task has this animal been trained to perform?
Employees can’t ask about the person’s disability, require documentation or ask that the service animal perform the work or task.
If it is determined that the animal is not a service animal, then we treat them under our pet visitation policy.
Comfort animals for emotional support, depression, or anxiety are not considered Service Animals. This is an important education piece that healthcare workers struggle with. The public does not always understand the difference between a certified service animal and the law that protects that animal, and a companion animal.

16. Service Animals Excluding a service animal from a “restricted area”.
General infection-control measures
Hand Hygiene
Personal Protective Equipment
gloves, gowns and masks
from an OR or similar special care areas (e.g., burn units, some ICUs, PE units, and any other area containing equipment critical for life support) is appropriate if these areas are considered to have “restricted access” with regards to the general public.
Infection control measure that dictate such limited access include the area is required to meet environmental criteria to minimize the risk of disease transmission

17. Service Animals
Exclusion of such an animal must be based on the actual behavior of the particular animal, not on speculation about how the animal might behave

18. Animal Assisted Therapy-AAT
The concept
The benefits of contact with animals
Goal-directed intervention
The concept- for AAT arose from the observation that some patients with pets at home recover from surgical and medical procedures more rapidly than patients without pets
Benefits- enhancing wellness in certain patient populations (e.g., children, the elderly, and extended-care hospitalized patients)
Goal directed intervention- that incorporates an animal into the treatment process provided by a credentialed therapist

19. Animal Assisted Therapy-AAT
Guidelines for establishing AAT programs are available for facilities considering this option.
Animals participating in either AAA or AAT sessions
good health
up-to-date immunizations and prophylactic medications (e.g., heartworm prevention)
These animals are brought in by a professional handler that understands where it is appropriate for the animal to travel to in the healthcare setting. These animals are specially trained not to react to eliminate the risk of any pet injuries.
Therapy dogs are frequently invited to visit schools, libraries, assisted living homes, hospitals and hospices
Therapy dogs do not require any special training

20. Personal Pet Visitation
Pets should, in general, be prohibited from entering the healthcare facility.
Exceptions can be considered if the healthcare team determines that visitation with a pet would be of benefit to the patient and can be performed with limited risk.
Policy at Sanford Health
Visitation should be restricted to dogs
The patient must perform hand hygiene immediately before and after contact with the animal.
We understand the value and importance of patients being visited by their pet. We want to partner with the public to make that happen. We have a policy in place that assures the safety of the patients, the pet and the staff. Through good communication with staff, the pet visit can be positive and therapeutic.
Apersonal pet may be allowed following the policy-example patient on rehab

21. Emotional Support Animal
Emotional Support Animal is a pet that helps alleviate symptoms of a mental or emotional disability through companionship and affection.
Unlike most types of assistance animals, such as service dogs, ESAs are not required to have any kind of specialized training or experience.
Much like pet visitation, we would allow emotional support animals to visit as well. With that being said, we do not have the capability to run a 24/7 vetinary service.
Another barrier we run into is although the animal is an emotional support animal to it’s owner, it may show aggression towards staff. If staff feel threatened by the animal it then becomes an unsafe environment for the patient.

22. Emotional Support Animal
To legally make your pet an emotional support animal
A licensed therapist must write you an ESA letter recommending an emotional support animal for your condition.
Someone can keep their cat or dog in no pet apartment with no pet rent or pet deposits.
Someone can have a pet fly with them, no cabin fees for the pet.

23. Identifying emotional support dogs for the public
Emotional support dogs are often identified by wearing an emotional support dog vest or tag
Some businesses, such as airlines, prefer to see an identification card or vest that indicates that the dog is an emotional support dog.
otherwise, their handlers will find themselves having to explain that their dog is an emotional support dog.

24. Emotional Support Animals in the Hospital
Patient’s Pet
Visitor’s Pet
Patient has a pet wanted to visit-follow the Animal visitation policy
Visitor-coming to visit a patient with their pet

25. Observations
ADA service animals behavior-jumping, not obeying, using the entrance rugs as a restroom
Female had a kitten hidden in her coat, running around in a patient room
Female patient that is reoccurring, patient carries the dog in her arms. The dog wears a tutu and a ADA service vest that the   When we asked what task does the animal provide, she replied it keeps me calm, she is my therapy dog.    
Male patient requested to have a dog present during a procedure
Family brought a dog in a bag into a restricted area.

26. Allergies? The American Academy of Allergy, Asthma, and Immunology
estimates that dog or cat allergies occur in approximately 15% of the population.
Minimizing contact with animal saliva, dander, and/or urine helps to mitigate allergic responses.
Some facilities may not allow animal visitation for patients with
underlying asthma
known allergies to cat or dog hair
respiratory allergies of unknown etiology
immunosuppressive disorders
Allergies and fear of dogs are not valid reasons for denying access or refusing
people to use their service animals.

27. Risks to Patient & Visitors
Animal Bites
Common pathogens associated with animal bites
Capnocytophaga canimorsus
Pasteurella spp
Staphylococcus spp
Streptococcus spp.
Rodents, exotic species, wild/domestic animals (i.e., wolf-dog hybrids), and wild animals whose behavior is unpredictable should be excluded from AAA or AAT programs.
Animal Bites therapists and handlers must take precautions to prevent animal bites.
Selecting well-behaved and well-trained animals for these programs greatly decreases the incidence of bites.
A well-trained animal handler should be able to recognize stress in the animal and to determine when to terminate a session to minimize risk.

28. Infection Control
The most important infection control measure to prevent potential disease transmission
Strict enforcement of hand-hygiene measures
Avoid direct contact with animal urine or feces
Appropriate clean-up of waste products
(e.g., using either soap and water or an alcohol-based hand rub) for all patients, staff, and residents after handling the animals
requires gloves and the use of leak-resistant plastic bags to discard absorbent material

29. Policy, who enforces it?

30. Summary Pet therapy and volunteer program guidance
Develop a written policy for animal-assisted activities and designate a liaison for such activities.
Allow only dogs to serve in animal-assisted activities.
Make sure all animal handlers have all required immunizations.
Require everyone who handles the animal to perform hand hygiene before and after contact.
Do not allow animals to come in contact with invasive devices.

31. Summary Service animals
Make sure hospital policy is compliant with the Federal Americans for Disability Act, and include a statement that only dogs and miniature horses are recognized as service animals under federal law.
Notify the infection control team if an inpatient has a service animal and discuss institutional policies with the patient.

32. Summary Personal pet visitation
Generally, do not allow pets to enter the facility.
Consider exceptions if the team determines a visit could benefit the patient and happen with limited risk. Even then, restrict visitation to only dogs.