Procedure to follow for injuries associated

Yale University
Institutional Animal Care
& Use Committee
New Haven CT
USA 06510

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Yale University
Procedure to follow for injuries associated with the care and use of non-human primates (NHP’S)

INTRODUCTION

Non-human primates (NHP) can transmit infectious agents to humans. Notably, exposures associated with NHP’s have the risk of transmitting Herpes virus B infection (Cercopithecine Herpes virus I). Any person with potential exposure, including an injury resulting in inflamed tissue without evidence of skin penetration must consult with the University Health Services, Employee Health (432-7978) or Urgent Visit (after hours) to determine the appropriate course of action and/or treatment.

The following protocol must be followed if an individual:

is bitten by a NHP and the bite penetrates or is suspected to penetrate the skin.
sustains an abrasion or a break in the skin occurs while handling NHPs, NHP tissues or equipment contaminated with NHP secretions (e.g. caging, transport chairs). This includes but is not limited to:

Bites
Scratches from NHPs
Needle sticks
Lacerations or other abrasions

is splashed in the eyes or other mucous membranes by NHP blood, other body fluids or material contaminated with NHP secretions or excreta.

PROCEDURE

Note: Gloves must be worn when assisting with these procedures.

THE INJURED PERSON SHOULD:

use a bite/scratch kit located in NHP facility offices. Instructions and items needed for appropriate wound care are included in these kits. These include:
- encourage the wound to bleed
- under running water, vigorously scrub the wound with a Betadine impregnated scrub brush for 10 minutes
- after rinsing the Betadine, use pre-moistened sodium hypochlorite towelette to soak the wound for at least 15 minutes.
if a bite/scratch kit is unavailable:
- encourage the wound to bleed
- wash with hot soapy water for 10 minutes
- scrub the wound with a solution of bleach and water (9 parts water to 1 part bleach) for at least 15 minutes.
irrigate splashes to eyes with 0.9% saline solution or, if unavailable, plain tap water, for 15 minutes.
inform an immediate supervisor or other staff member that an incident has occurred and convey the following information:
- animal number
- animal location
- alternatively, call the Animal Resources Center office at 785-2526.
notify the Department of Employee Health at 432-7978 or 432-0071 of the exposure and arrange for treatment. If the Employee Health Department is closed or unavailable the employee should report to Urgent Visit at the Yale University Health Services for evaluation and treatment.
complete a “ Health Service Appointment and Report” form obtained through the employee’s departmental business office.
bring a copy of this protocol to Urgent Visit (available in NHP offices). This protocol is on file at the YUHS external website under the Employee Health Department.
be alert for any signs or symptoms of zoonotic disease for the following four weeks and notify Employee Health about any suspected illness. See below section B.9.

YUHS SHOULD:

Verify that the wound has been cleansed. If not, cleanse as in section A.
If the wound is open, re-cleanse the exposed area by washing with povidone-iodine, chlorhexidine, or detergent soap for 15 minutes for a skin wound, or irrigate eyes or mucous membranes for 15 minutes with sterile saline or water.
Obtain a detailed history of the exposure noting time, monkey identification, and any personal protective equipment that was in place (such as gloves, face shield, etc), adequacy and timing of post exposure cleansing on site.
Contact Veterinary Clinical Services (785-2501) to review pertinent health information about the monkey.
Draw a red top tube and label it “ post monkey bite sera for Herpes B Antibodies” instruct lab to spin and hold at YHP, and store tube in YUHS refrigerator overnight. Use a miscellaneous lab slip for this---DO NOT USE A YHP Clinical Lab slip or send the samples out.
Swab the wound for viral culture using Bartel’s viral transport media (available in the lab or in the Urgent Care refrigerator) and refrigerate.
Treat the wound as needed, including a tetanus immunization if indicated.
For deep bite wounds (e.g. penetration of underlying muscle, connective tissue), consider prophylaxis with antibiotics sensitive to normal oral flora,( such as Augmentin or other appropriate bite wound regimen)

Notify the Department of Employee Health of the incident on next working day so Employee Health can arrange to send the samples to the clinical reference laboratory for B virus.
Employee Health will consider having a Herpes B virus PCR detection assay performed on the viral swab, in cases of severe wounds, as this test is more rapid and sensitive.

The patient should be instructed to return to have sera re-drawn at 3 weeks post exposure to re-check for the development of Herpes B antibodies.
The patient should be counseled to look for and report any symptoms of possible infection with Herpes B virus. These may include:

vesicular eruptions at the site of injury
localized numbness, pain, itching
flu like illness with muscle aches
fever and chills—especially any fever over 101.3 lasting more than 2 days
severe headache lasting more than 24 hours
loss of balance or muscle coordination
shortness of breath

Any employee who is immunosuppressed also should be informed about the potential increased risk of infection following exposure due to the immune system not functioning normally.

Consider recommending post exposure prophylaxis with Valacyclovir, 1g po q 8 hr for 14 days for exposure to Herpes B virus. See below for recommendations regarding post exposure prophylaxis. ( Acyclovir 800mg po 5 times a day for 14 days is an alternate) A small supply of Valacyclovir is in Urgent Care pharmacy pixis.

Recommend Prophylaxis if:

Exposure involves broken skin or mucous membrane contact with macaque monkey that is known to be ill, shedding virus, or has lesions compatible with Herpes B.
Any exposure where there was inadequate on site cleansing
Deep puncture bites or other wounds to head, neck or torso
Exposure to fluid from monkey nervous system (or lesions suspicious for Herpes B
Lesions which had a positive culture for Herpes B

Consider Prophylaxis for:

Any mucous membrane exposure or lacerations (even if cleansed adequately)
Needlestick from ill macaque or injury involving potentially infected fluid or cell culture

It is not recommended to give prophylaxis for injuries that do not break the skin, or for injuries involving a non-macaque species which was not likely to be harboring B virus.

Schedule follow up serologic testing for Herpes B Antibodies at 3 months post injury for any patient who has received post exposure prophylaxis.

Addendum: Laboratory for Human specimen submission

Dr. Julia Hillard
B Virus Research and Resource Laboratory
Georgia State University
Phone: 404-651-0808

PO Box 4118
Atlanta, GA 30302-4118

(note specimens are sent frozen, in a plastic tube, via Fed Ex carrier using proper labeling for biohazards/ clinical specimens)

THE EMPLOYEE’S SUPERVISOR OR OTHER APPROPRIATE STAFF MEMBER SHOULD:

identify the animal involved.
arrange for “DO NOT FEED” sticker to be put on animal’s cage.
confirm that Veterinary Clinical Services (VCS) was notified that an incident has occurred and which animal is involved.
confirm that the employee has gone to YUHS and that the Department of Employee Health (432-0071) was notified.
fill out “ Department Report of Injury Form”, sign and immediately fax to Workers Compensation (Fax number 432-7575).
send “ Department Report of Injury Form” to department head for signature. Note: Form requires animal number.

VETERINARY CLINICAL SERVICES SHOULD:

initiate bite/scratch record and maintain copies of paperwork submitted to and from virology and NIH B Virus Resource Laboratory until case is completed (kept in Primate Book).
examine the animal (by a veterinarian) for lesions indicative of zoonotic infection, preferably within 8 hours and no later than 24 hours post exposure.
obtain swabs for viral culture from the NHP’s mouth, both conjunctiva, vagina and from any lesion noted at the time of physical exam. Swabs and transport media for viral culture (Bartels Viral Transport) are available in the VCS pharmacy refrigerator and in the primate area refrigerators. Culture media must be kept cold during transport. Store transport media containing swabs in -80°C freezer located in virology lab until shipped. Submit swabs in transport media with the serum from initial blood sample.
- For exposure during a terminal procedure (e.g. perfusion) obtain a tissue sample from exposed site in the animal, store in viral culture media at -80°C for viral PCR.
draw blood from the animal during initial physical exam and 2-3 weeks after the injury. Centrifuge blood, freeze sera, and store in VCS freezer until shipment. Submit the animals’ initial sera, and swabs for culture as soon as possible post injury and follow-up sera when drawn.
notify Chief of VCS, Attending Veterinarian, and the Chief, Department of Employee Health promptly if any samples test positive.
convey the results of serology, when they become available, to the Chief, Department of Employee Health at UHS 432-007l.
when the case is completed file in the Bite/sScratch book, and copy virology results to the animal’s record.

ENDORSED BY THE IACUC: 10/18/2006

Date revised: 10/19/98, 4/24/00, 6/19/00, 6/25/02, 12/04/02 , 5/5/03, 5/11/04, 8/22/06
Reviewed By: James Macy, Director of Yale Animal Resource Center, Randi Palmisano, Manager of Regulatory Services, Dorothy van Rhijn, Chief of Employee Health

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