Biosecurity in Hospitals

Chapter 29

Biosecurity in Hospitals

Helen Aceto

The purposes of this chapter are to provide a brief overview of biosecurity and to outline specific practical recommendations for the management of infection risk in equine hospitals.

What is Biosecurity and Why Do We Need It?

In veterinary hospitals, the original meanings of the terms biosecurity (preventing introduction of a disease agent into a population) and biocontainment (controlling spread of an introduced agent) have been conflated so that biosecurity, often used interchangeably with infection control, refers to all practices intended to prevent or limit introduction and spread of infectious diseases within a group of patients and their human caregivers, thereby protecting human, animal, and environmental health against biologic threats. The nature of medicine and mission of veterinary hospitals are such that animals clinically affected by the very agents that have the potential to spread among the hospital population, as well as subclinical carriers that may go unrecognized, are always likely to be present. Moreover, hospitalized animals are not the same as animals in the general population. In the hospital, horses are more likely to shed or acquire an infectious agent than those in the general population because they are more likely to be under stress, may be less able to respond immunologically to infectious agents, have altered nutrition or disturbances in normal flora, may be receiving antimicrobials, may undergo procedures that are known risk factors for infection of various types, and are concentrated in close proximity with other animals that have similar risk factors. Additionally, horses come from different herds, so every admission mixes horses from separate populations, thereby providing an opportunity to introduce infectious organisms to potentially naïve individuals. Equine hospitals are undoubtedly places where introduction and reintro­duction of infectious agents occurs and where contagious disease-causing organisms reside (a greater proportion of which are multidrug resistant [MDR] than in the general community), may be present in high numbers, and can come into contact with susceptible animals. The fact that hospitals are themselves nodes in the contact network of equine populations means that their role in disseminating infectious agents to the rest of the population should also be borne in mind when considering the need for biosecurity. The standard of care at every veterinary hospital should therefore include a high standard of hygiene, awareness of the dangers of transfer of infectious agents between both animals and people, and procedures to reduce infection risk wherever possible. An infection control program (ICP) aims to establish those policies and procedures necessary to accomplish the objective of effectively managing and reducing infection risks, including infections that are hospital acquired.

Development and Implementation of a Biosecurity Program

There is no interchangeable, one-size-fits-all program that is appropriate for every veterinary facility, but certain aspects of an ICP should be considered by all equine hospitals. No matter what the size of the clinic, the need to engender support at all administrative levels and to involve and inform all hospital personnel in the process is important to success. The most effective ICPs are both proactive and evaluative; the ideal way to ensure this is to have an individual (or individuals) dedicated to biosecurity oversight and reporting. Although this may be possible and desirable at large clinics, it may not be feasible for small hospitals. For the latter, having someone proficient in data management who is capable of reviewing and manipulating surveillance data, monitoring infection status and infection control activities on a daily basis, and then reporting to a veterinarian or veterinarians responsible for setting policy may be a reasonable alternative. The basic steps necessary in establishing a comprehensive ICP are summarized (Box 29-1); although focused on the small to medium-sized hospital, the process is inherently similar for all sizes and types of equine hospital. The degree to which an individual equine clinic implements biosecurity practices is, however, contingent on a number of factors, including size and type of caseload, facility size and design, personnel and economic issues, and level of risk aversion.

Box 29-1

A Biosecurity Program for Small to Medium-Sized Clinics

1. Appoint a senior member of the practice to be in charge of infection control.

2. Consider designating a member of the technical staff to conduct daily activities, including monitoring, data gathering, and proper implementation of preventive practices, among other duties.

3. Review incidence of the following:

a. Contagious disease-causing agents, such as Salmonella spp, Streptococcus equi equi, equine herpesvirus type 1 (EHV-1), equine infectious anemia, and other pathogens as applicable in your hospitalized patients and practice referral area

b. Incisional infections and other hospital-acquired infections in your patients

c. MDR bacterial infections; collate available antimicrobial susceptibility profiles.

4. Collect information on a, b, and c above, prospectively.

5. Designate an isolation area for hospitalized patients suspected of infection with Salmonella spp, Streptococcus equi equi, equine herpesvirus type 1, equine infectious anemia, and other pathogens as applicable (see Box 29-2). Develop policies to support this area.

6. Review available facilities and personnel; determine whether to accept horses that may require isolation (see Box 29-2). Even if you decide against accepting cases requiring isolation, facilities are needed for horses that develop infections during the course of routine hospitalization.

7. Review types of cases treated and group into broad risk categories. Considering your facilities and personnel, assess the practicality of segregating horses from different risk categories in separate areas of hospital.

8. Review facilities and traffic patterns (animal and human) with infection control in mind; where practical, make any necessary changes.

9. Determine incidence of contagious diseases and hospital-acquired infections in the population as the foundation for ICP and a means of assessing endemic rates of infection. Based on the findings, design a prospective surveillance plan, which may involve targeted collection and submission of samples for bacterial culture from patients and the hospital environment, surveillance for hospital-acquired infection using syndromic methods based on real-time recognition of clinical disease signs (e.g., inflammation) and body systems (e.g., gastrointestinal tract) rather than more costly and time-consuming laboratory diagnoses. Even if size and character of caseload do not warrant an active surveillance program, you must still closely monitor patients and results of clinical submissions for infection problems. Have an action plan in case evidence of problems is detected that includes criteria that automatically trigger an investigation and the appropriate response.

10. Review antimicrobial use in your hospital; follow prudent use guidelines, and if necessary, set specific policies based on the incidence and nature of MDR infections.

11. Develop protocols and schedules for cleaning and disinfection, waste disposal, and maintenance of surfaces to ensure that they remain sealed and cleanable.

12. Educate your veterinarians, all staff, and your clients about the need for vigilance and the infection control policy you have developed. Make sure that clients are informed about infection risks and that all such communications are properly documented.

13. Regularly review the data you are generating and the adequacy of the policy.

14. Constantly evaluate to optimize the benefit-to-risk and benefit-to-cost ratios.

Components of a Biosecurity Program

Preventive Measures

Separation by Risk

Patients should be divided into risk categories: high, medium, and low are convenient and easily understood designations. As a guide, low risk comprises elective cases, whereas medium risk would include many nongastrointestinal emergencies and inpatients that receive antimicrobials for more than 72 hours. In some instances, high-risk categorization is largely predicated on vulnerability to infection, such as with neonates, particularly those that are critically ill. For others, high risk indicates presence of known or suspected infection or a past experience with similar patients that suggests the animal represents a risk to other patients, to the hospital environment, and to personnel in the case of zoonotic agents. There is ample evidence to indicate that equine colic patients are a dual threat in that they are at high risk for both developing various types of infection and shedding enteric organisms, notably Salmonella spp. Wherever possible, patients in different risk categories should be housed separately, and cross-traffic of both animals and humans should be limited or even prohibited (e.g., cross-traffic with isolation patients). If the risk status of a patient changes during hospitalization, it is critical that the client is informed immediately and that such communications are properly documented in the medical record. Every equine hospital should have an area designated for patient isolation (Box 29-2), ideally one that is physically separated from lower risk animals. At a minimum, a stall or stalls away from high traffic should be designated for isolation use. When occupied, access can be limited by placing barriers around the stall or between it and other areas of the hospital; although less than ideal, using something as simple as cones and tape can work.

Box 29-2

Determining Which Animals Should Be Considered for Isolation (or Barrier Precautions, at a Minimum)

Any animal demonstrated to be shedding Salmonella spp in feces or that has gastrointestinal reflux, regardless of clinical signs.

Any animal with acute-onset diarrhea.

Any animal with unexplained fever and abnormal white blood cell count.

Diarrhea associated with antimicrobial administration or conditions such as grain overload; evaluate other clinical signs to determine whether isolation is necessary.

Any horse with colic that develops clinical signs consistent with salmonellosis.

Any equid with known or suspected strangles or that comes from a facility where there are active strangles cases.

Any equid with neurologic disease where EHV-1 is suspected or where the patient may have been in direct or indirect contact with EHV-1–positive equids.

Any mare that has a late-term abortion in which EHV-1 infection is the suspected cause.

Rabies suspects.

Any animal with confirmed or suspected infection with cryptosporidium.

Any animal with a confirmed methicillin-resistant Staphylococcus aureus infection, particularly when there is open drainage from the site of infection.

Any animal with MDR infection that represents a potential nosocomial or zoonotic threat.

All severe cases of ringworm, infestation with ectoparasites, and bacterial dermatoses.

Any animal with a suspected foreign animal disease or other disease reportable to the U.S. Department of Agriculture or the World Organisation for Animal Health must be isolated and the appropriate authorities contacted.

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Jul 8, 2016 | Posted by in EQUINE MEDICINE | Comments Off on Biosecurity in Hospitals

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