When not to bring your dog to work
In some situations, bringing a pet to work might be acceptable. In other situations, it's totally inappropriate. A UK dentist learned that the hard way.
Ian Hulme-Ribsy, a dentist, was found guilty of unprofessional and inappropriate conduct for several bad behaviours. One was that he brought his dog to his dental clinic and failed to clean his hands after handling it. That's a pretty blatant breach of basic infection control practices, in the sense of both having an animal in a patient care area (outside of a structured visitation program) and failure to use basic standards of hygiene to reduce the risk of disease transmission. (It's particularly troubling when you consider that as a dentist the man would be putting his unwashed fingers directly in patients' mouths.) It's pretty remarkable considering how much attention is generally paid to infection control in the dental world.
Also included in his list of bad behaviours was giving patients sedatives in liquid form without measuring. He'd just pour some into a plastic cup. Reckless disregard for dosing of sedatives is probably a bigger concern than the dog issue, but both show poor judgment.
Mr. Hulme-Ribsy didn't lose his license, but must practice with restrictions. "... Hulme-Rigby must work under supervision and take courses in record keeping, infection control and dental practice ethics. He must undergo annual infection control and record keeping audits, and is banned from administering benzodiazepine drugs, or any other sedatives. Hulme-Rigby’s case will then be reviewed to decide if he is fit to practise without restrictions."
Do you wash your hands at a petting zoo?
Petting zoos can be great events (I've said it before and I'll say it again!). I end up visiting many with my kids every year. Despite the fact that a few petting-zoo-associated disease outbreaks also occur every year, and despite the fact that I deal with infectious diseases every day, I still don't get too concerned about the risk to my family.
Why not?
The main reason is that I can control one of the most important disease prevention measures: making sure my family washes their hands after being in the petting zoo (along with some other common sense measures).
Hand hygiene is a critical infection control tool, and poor hand hygiene practices are often part of the problem in outbreaks. Figuring out how to improve hand hygiene is an important research area, albeit one in which few people are working.
A paper by Maureen and I, published recently in Epidemiology and Infection, looked at hand hygiene compliance in a petting zoo and how to improve it. The study involved using webcams to remotely and discretely observe hand hygiene practices in people attending a petting zoo. We've previously done observer-based studies, where you have someone standing there watching, but it's possible that this method falsely elevates results because some people might notice they're being watched and be more likely to wash their hands. It's also easier to record a lot of data and evaluate it over time (i.e. by watching it on video), than try to collect everything accurately in real time.
The published study involved a large petting zoo at the University of Guelph's annual open house. It's a well designed and operated event, which needs to be considered when evaluating the results, since petting zoos vary greatly in quality.
Overall hand hygiene compliance at this particular event was 58%. That means 58% of people that came into the petting zoo washed their hands or used a hand sanitizer on the way out. (It doesn't mean they all did it well, but they at least they did something). In some ways, that number's good, when you compare to our earlier petting zoo observation study, (or even to results of hand hygiene rates of physicians in some hospitals). However, for such a short-term activity where there is easy access to facilities to wash hands or use a hand sanitizer, there's much room for improvement.
During the petting zoo, a few thing were changed at defined times to see if they would improve hand hygiene rates. Two things resulted in increased hand hygiene compliance; a combination of petting zoo personnel actively offering visitors hand sanitizer near the exit and improving hand hygiene signs, and having personnel walking through the zoo reminding people to wash their hands. This suggests that people need an active reminder to clean or sanitize their hands. Whether they don't think about it, or can't be bothered unless someone points it out, is unclear, but having personnel encouraging hand hygiene is something to consider to help improve infection control. It's practical for short-term events like petting zoos at fairs and similar exhibits, although perhaps not as practical for permanent exhibits.
People who entered pens or touched animals were more likely to wash their hands than people who didn't. This is presumably because people who had contact with animals were more likely to recognize a risk. However, while people who touch animals are presumably at higher risk, simply being in the area is enough to pick up an infection. In some outbreaks, people who went into the petting zoo but never touched an animal got sick. That's why there is a need to remind people that everyone must wash their hands after leaving a petting zoo, not just those who actually petted the animals.
A few other concerns were noted. Despite warnings on prominent signs, 10% of people carried food or drink into the petting zoo area. This probably increases disease transmission risks since people may eat or drink before they wash their hands, or directly contaminate their food or drink while in the petting zoo area.
Overall, hand hygiene rates weren't bad (and were better than I was expecting), but there is still room for improvement. Considering how quick, easy and cheap it is, there's no reason not to strive for 100% compliance.
Whooping cough and pets
A large whooping cough (pertussis) outbreak has been ongoing in people California in 2010. This bacterial infection, caused by Bordetella pertussis, is a highly transmissible disease that can result in serious problems (including death) in young infants. At last report, there were over 6000 cases of whooping cough, making this the largest outbreak in 60 years. Over 200 infants have been hospitalized, and there have been at least 10 deaths. Nine of the 10 deaths were in infants less than two months of age. Infants in this age group have little to no immunity to the disease because they haven't been vaccinated, and they are more prone to severe complications.
Bordetella pertussis is a human bacterium. It does not infect animals and animals are not direct sources of infection. (Actually, experimental infection of neonatal puppies with large doses of B. pertussis can result in shedding of the bacterium by a small percentage of dogs, but that's not particularly relevant to the normal household situation). Therefore, people don't need to worry about infecting their pets and pets passing the infection on to other people. However, it's not impossible that pets could play an indirect role in transmission. A pet's haircoat could possibly become contaminated with the pertussis bacterium from someone coughing around it, or touching it with contaminated hands. The bacterium could survive on the haircoat for a while (probably days), and someone could potentially get the bacterium on their hands by petting it, and subsequently become infected.
What are the odds of this happening? Who knows. It's not something that anyone has investigated, as far as I know.
Could dogs and cats be important sources of pertussis in households? Probably not. I assume that if there is a person with whooping cough in a household, that person is more likely to be the source of infection for other people than a pet.
Could pets spread pertussis outside the home? That might be a more realistic concern. People with pertussis might keep themselves away from others and stay at home, but if they contaminate their dog's coat and the dog meets people on a walk or at the park (or at a veterinary clinic, or anywhere else), I have to wonder whether there could be the potential for spread of the disease.
What should we do about this? Common sense should prevail, and itt's important for pertussis as well as other diseases. If someone in the household has an infectious disease that is transmissible and for which a pet could potentially be a vector, some basic precautions should be taken. Good attention to hygiene might help reduce contamination of the pet's haircoat. This includes regular handwashing (especially after coughing and before petting an animal), avoiding coughing close to the pet and not letting the pet sleep close to the person's head. Keeping the pet away from people outside the house, or at least limiting it's contact with high-risk people might also be useful. In particular, keeping pets that might have been contaminated away from infants would be wise.
Overall, the risks are very low. We don't need to fear dogs and cats as potential pertussis vectors. However, in the absence of proof that there's no risk, and with a highly transmissible and potentially serious disease, use of some simple infection control measures makes sense.
Biohazardous cell phones
It's amazing how attached people are to their cell phones. Many people will answer them without any thought of what else is going on. It's something I've seen in veterinary hospitals where wireless or cell phones are the primary mode of internal communication. The natural tendency to answer the phone often overrides the thought process of "are my hands covered in pus, blood or some other gross material that I should perhaps remove before touching this piece of plastic that will spend a lot of time against my face and which may go home with me?" We've grown some interesting things from cell phones and pagers, as have others.
A recent paper in the American Journal of Infection Control (Sadat-Ali et al 2010) provides yet another example of this. In this study, the authors cultured cell phones of 288 health care providers over a six-month period.
- 44% of phones were contaminated with "potentially harmful" bacteria. There's no description of what they considered "potentially harmful" and I'm surprised that the percentage wasn't even higher.
- MRSA was isolated from 7.3% of phones, from people in wards, the emergency room and the operating room.
- 31% of people said they occasionally wiped down their phones with alcohol swabs. People who said they did this were significantly less likely to have contaminated phones.
Is this really surprising? No, not at all. We don't live in a sterile environment, and the more contact with healthcare environments, the greater the chance of contamination with healthcare-associated microorganisms. We also know that hygiene practices associated with cell phones are certainly not very common, nor have optimal ways to reduce or remove contamination been investigated.
Is this a problem? It's hard to say. Just because cell phones can become contaminated, that doesn't mean they are sources of infection. They are one of many, many potentially contaminated environmental surfaces. However, given the close contact with them and the potential that someone would touch a cell phone and then a patient, it's something that shouldn't be ignored.
Are health care workers' phones worse than other people's phones? It's hard to say. This study didn't look at a control group of non-healthcare workers. I suspect that phones owned by the general public are often contaminated as well, though perhaps not with the same range of microorganisms.
How can we reduce the risk of contamination? It's simple: wash your hands regularly. If healthcare workers washed their hands when they are supposed to (especially before and after patient contacts), the risk of contamination and the implications of cell phone contamination would be greatly reduced.
Like a lot of things in infection control, reducing the risks of this potential problem is pretty easy in theory, but harder in practice, because the draw of that ringing phone is pretty powerful psychologically.
Image from http://cancergrace.org
Infection control...how things have changed
Infection control is a constantly evolving and expanding area - for the good. Paying close attention to infection control in human hospitals is a relatively recent phenomenon, and the advances in infection control are now having an impact outside of hospitals. Pandemic H1N1 influenza drove a lot of changes, but there's been a general increase in awareness of the need for routine infection control in the greater community. This applies to veterinary clinics and living with animals, but is also evident in everything from protocols in workplaces to summer camps.
We're getting ready to send my oldest daughter to summer camp for 12 days. Back in my time, I doubt there was much of an infection control plan for summer camps. If anything, it was probably "don't puke on the other campers and try not to eat too much dirt."
Oh, how things have changed! Last night, we received an email from the camp reminding us to keep our daughter at home if she is sick and outlining their infection control program. Among the infection control measures are:
- Having 2 12-foot handwashing stations outside of the Dining Hall, with everyone required to wash their hands before eating
- Having sinks equipped with handwashing supplies present in all buildings
- Having hand sanitizers throughout the Dining Hall and in every cabin
- Training staff in infection control protocols
- Cleaning cabins every day, with daily inspections of cabins by their "Public Health Supervisors"
- Daily spraying down of surfaces like Dining Hall tables, door handles, toilet handles, taps etc. with disinfectant
- Screening of all kids by one of the Registered Nurses on the first day of camp
Pretty impressive effort, in my opinion. Like everything else, compliance is critical and having good facilities and plans doesn't guarantee good practices, but the efforts put into developing this program and communicating it suggest that they'll be paying attention to it. Even with a good program, camps are an excellent breeding ground for infectious diseases and are perpetually an outbreak waiting to happen, but a good infection control program should greatly reduce the risks.
Live every day like you have MRSA
I was giving a talk on infection control at a conference in Geneva a couple of days ago, and during a discussion with someone after the talk, I told them to "Live every day like you have MRSA." Not surprisingly, I got a bit of a strange look in response. I wasn't trying to say, "live your life to the fullest because you never know what will happen." Rather, I was trying to get the point across that healthcare workers in both the veterinary and human systems need to realize that at any point in time they could be carrying MRSA, along with various other harmful microorganisms.
People in patient care positions need to make the assumption that they are always a potential source of disease, and act accordingly while doing their jobs. If someone knew they were a carrier of a bug like MRSA, they'd likely do a better job with routine infection control practices such as handwashing. But, you rarely know whether you're carrying MRSA or not, and it's better to go on the assumption that you are and be diligent with your infection control measures.
The same basic concept applies to different situations, such as how people in the general population behave, and how they interact with other people and animals. In some ways, everyone should assume that they are carrying an infectious disease like influenza, and that every person or animal they encounter is carrying something infectious. (In reality, this is actually true, since everyone is carrying something potentially infectious in or on their body at any given time, it's just that most of the time it's not particularly serious or transmissible organisms).
There's a line between prudence and paranoia, and we don't want to create a population of germophobes who won't leave the house. However, we want to increase awareness so people do a better job of things like washing their hands and covering their mouths properly when coughing or sneezing. Assuming that you and everyone around you is mildly biohazardous maybe a way to do just that.
World Hand Hygiene Day
Today is World Hand Hygiene Day, an occasion being promoted by the World Health Organization’s (WHO) “SAVE LIVES: Clean Your Hands” campaign. This WHO initiative is aimed primarily at improving hand hygiene in healthcare facilities around the world, in order to help reduce healthcare-associated infections (HAIs) (e.g. infections that people develop while in hospital). Also to mark World Hand Hygiene Day, the CDC has launched its new hand hygiene website, which has tons of information on hand hygiene basics, guidelines, resources for promotional campaigns, and information for patients.
Hand hygiene is one of the most important aspects of controlling infection in human hospitals, but that’s certainly not the only place where it can be beneficial. It is also very important in veterinary hospitals, to help prevent the spread of infection between animals, whether they’re sick or they’ve just had surgery. Here on the Worms & Germs blog, we also talk a lot about using proper hand hygiene to help prevent the spread of zoonotic pathogens from pets to people. Even at home, just like in hospitals, our hands are one of the most common ways bacteria and viruses move from one surface to another, from one person to another, and from just about anything into our mouths (either directly or via our food). Dirt on your hands is easy to see, and it makes it easy to remember to wash your hands. The bigger concern is the microscopic amounts of dirt and germs on your hands that you can’t see, and the best way to take care of that is really to make hand hygiene part of your routine. Make it something that just naturally goes along with playing with your pet, or cleaning the cat’s litterbox, or poop-scooping after your dog. Although most of the time it may not be a matter of saving lives, it’s certainly a matter of saving people from being sick. Make hand hygiene a habit, and don’t just do it for yourself – do it for all the people (and pets!) you live with and interact with everyday.
Fewer sinks in veterinary clinics??
Click here for a link to a presentation by an architect about veterinary clinic design.
This video clearly shows why people that are designing clinics need to be thinking about infection control (and that some are clearly not doing so). This person talks about the trend towards not placing sinks in exam rooms. This is news to me, and a major concern, because one of my major points when consulting on clinic design is making sure there are sinks in all exam and treatment areas. The farther you have to walk to find a sink, the less chance you’ll wash your hands and the greater chance you’ll contaminate things on the way to the sink.
One of this person's arguments for not putting sinks in exam rooms is truly ludicrous. Basically, he says that pet owners are more and more in tune to hand hygiene, and if they see a sink and someone not use it, they get concerned that the vets hands are dirty. His reasoning is that not having a sink will prevent people from thinking about hand hygiene issues. For one thing, I think he’s underestimating the intelligence of pet owners - they don’t need to see a sink to think about hand hygiene. People are becoming much more aware of the need for healthcare providers to wash their hands, and this is filtering down to their perceptions of veterinarians as well. Instead of taking sinks out of exam rooms, if a vet is concerned their clients have a negative perception of their hand hygiene practices, there's a simpler solution: actually practice good hand hygiene (and do so where owners can see it so they can be confident it's being done!). The architect is correct that hand sanitizers are now more widely used, but he is incredibly wrong with his assumption that hand sanitizers replace hand washing. They don’t. Hand sanitizers are great but handwashing is still required in many situations.
Hopefully this architects assessment that sinks are disappearing is wrong. Vets and architects need to think about infection control when designing clinics. It’s easy to incorporate good infection control when building a clinic but very hard to retrofit a poorly designed clinic.
PInworms and pets
Pets as a source of pinworms in people (especially children) has been a widespread misconception. A recent article at www.medicalnewstoday.com gives a good overview of pinworms in people and has a nice section about pets.
"Pinworms that affect humans cannot infect animals or pets. However, some microscopic eggs may land on a pet's fur and then be transferred to human hands when stroking (petting). It is important to remember that the problem is not the pet, it is human hand washing and hygiene."
This nicely explains two key concepts:
- People are the source of human pinworms.
- Hand hygiene is an important routine practice around pets.
Preventing infections in the home
There is a nice, concise commentary in the most recent issue of the Canadian Medical Association Journal about preventing infections in the home. It covers three important organisms: MRSA, Clostridium difficile and vancomycin-resistant enterococci (VRE). An excellent aspect of this particular commentary is its relatively low-key approach, with an emphasis on routine, basic practices such as hand hygiene. It also includes some comments about pets that are similarly well-balanced and go along with a lot of what we've been saying on Worms & Germs Blog. For example, in discussing MRSA, they state:
"Because domestic pets may serve as a reservoir of MRSA, hands should always be washed thoroughly with soap and water after contact with animals or their feces. In cases of outbreaks within a family of an infection caused by community-associated MRSA that cannot be arrested, a colonized pet may need to be temporarily removed from the home. However, it may be prudent to re-emphasize the importance of personal hygiene before taking such a drastic measure."
Overall, it's a commentary you might find useful. It can be downloaded by clicking here.
E. coli O157 outbreak tentatively linked to livestock show
An outbreak of E. coli O157 - the particularly nasty strain of E. coli that can cause hemolytic uremia (a serious kidney disease) and death - has been identified in Colorado, and signs are pointing toward a livestock show as the source. So far, 20 people have been identified as infected, including 19 children. The exact source of the infection is not clear, and could be food, water or contact with animals. However, considering the high percentage of children, the petting zoo is a likely source.
As we've discussed previously, petting zoos can be fun and educational events (particularly for children) but are always associated with some degree of infectious disease risk. Petting zoos are often poorly equipped to handle these risks, as we reported in a paper in Clinical Infectious Diseases a little while ago. Petting zoos are a risk because animals that appear healthy can still carry infectious diseases. This is particularly true for E. coli O157, which can be carried by perfectly healthy cattle. Despite the possibility of exposure to E. coli and other potentially harmful microorganisms, the potential for disease can be greatly reduced with some very basic measures, like handwashing, not eating in the petting zoo, handwashing, keeping baby bottles and other items out of the petting zoo, handwashing, and having signs encouraging people to wash their hands. The people in charge of this event stated that they had a well organized petting zoo with handwashing stations available, and that may very well be true. Having access to handwashing facilities is a critical step, but it doesn't do anything if people don't use them. Unfortunately, poor compliance with handwashing is very common and is one of the weakest links in infection control at petting zoos.
- Always wash your hands after leaving a petting zoo.
- Don't eat in a petting zoo area.
- Don't take items into the petting zoo that will go into a child's mouth, like bottles, cups and soothers.
Clean hands, a New Year's Resolution
I've never been one to make New Year's resolutions. I figure if it's important and something I should do, why wait until January 1 to start? However, New Year's resolutions can be a good way to get people thinking about ways to improve their health. NovaNewsNow.com has a good idea for a practical and useful resolution: better hand hygiene. The article contains some good tips on when hand hygiene is needed. Hand hygiene is the term used for hand washing or use of alcohol-based hand sanitizers, and hand hygiene is one of the most (if not the most) effective and important infection control tools in hospitals, and in the community. Despite this, most people don't perform hand hygiene often enough (or properly), resulting in unnecessary risks of disease transmission.
Have a Happy New Year, and clean your hands.
Pets and immunocompromised people
There was an interesting article in USA Today about the increasing recognition of the positive role that pets can play in patients recovering from serious disease, and how contact with pets can sometimes conflict with disease transmission concerns in these same patients. The attitude towards pet ownership among physicians is highly variable - some recognize the strong human-animal bond and its positive effects, while others see pets as unnecessary infectious disease risks. The infectious disease concerns are heightened in patients with compromised immune systems, to the point that sometimes people are told to get rid of their pets if they are severely immunocompromised. However, more and more pet owners, veterinarians and physicians are beginning to question if this is truly the best approach.
The USA Today article describes the experiences of a cancer patient whose greyhounds were "banished to a caregiver on doctors’ orders". Considering she was at high risk for (potentially fatal) infectious disease because of chemotherapy, bone marrow transplant, stem cell transplant and immunosuppressive drugs, it’s not surprising that there was concern about the pets. After researching the risks, and measures she could take to reduce those risks, the patient convinced her doctors that the risks from her dogs were not as great as the benefits from having them around, and so the dogs returned home. While everyone’s relationship with their pets is different, the patient felt that the return of her dogs was an important step in her recovery, stating "There's no question that having (the dogs) with me these past few months made a huge difference in my recovery".
Infectious disease transmission from pets to people is certainly a real issue, and it is of particular concern in people with weakened immune systems. There is not, nor will there ever be, a "no-risk" pet. Every contact with a pet, just like every contact with another person, carries with it some degree of risk of disease transmission. What needs to be considered is the trade-off, the risks versus the benefits. In some people, the risks are greater than the benefits because of the severity of disease, type of pet, the person's ability (or more likely inability) to interact with the pet. In other people, especially those who have a very strong bond with the animal, the positive social and emotional benefits of pet ownership may greatly outweigh the associated disease risks. The article contains a great quote from Dr. Ray Pais, a pediatric hematology/oncology specialist, saying "Our young patients have already given up so much, I see no reason at that moment for them to also lose the dog."
People that have compromised immune systems need to have a serious discussion with their physician, veterinarian and family about the best thing to do with their pets while they are sick. While there is very little research in this area, taking a few common sense precautions should reduce the risks of disease transmission. These include:
- Avoiding contact with stool
- Frequent handwashing
- Preventing licking of the person by the pet
- Proper training to reduce the risk of bites and scratches
- Keeping cats indoors
- Following a good preventive medicine program for the pet
More information about Immunocompromised Pet Owners will be available soon on the Worms & Germs Resources page. The CDC also has useful information on its website about this topic.
Thanks to Dr. Doug Powell of Barfblog for forwarding this article.
Your mother was right! Wash your hands
You may notice a recurring theme in many of our posts and on virtually all of the information sheets on the Worms & Germs Resources page: an emphasis on handwashing. There is increasing emphasis on hand hygiene (i.e. hand washing and use of alcohol hand sanitizers) education in hospitals because the hands of healthcare workers are a major (if not the most important) means of disease transmission between patients. Despite hand hygiene being easy, cheap and effective, people rarely wash their hands as often as they should, and they often don't do it properly.
Most of the research about hand hygiene that has been published has focused on its use and impact in human hospitals, but this area is now also being studied more with regard to animals and veterinary medicine. A study published earlier this year in Veterinary Microbiology provided more evidence that hand hygiene is a critical infection control measure when dealing with animals. The study, coordinated by Dr. Maureen Anderson (of Worms&Germs fame) looked at MRSA carriage rate in veterinarians who work with horses. In addition to finding a high rate of MRSA carriage among these veterinarians (which was consistent with other reports indicating that equine vets are at higher than average risk for exposure to MRSA), the study looked at factors associated with MRSA carriage. Vets that reported routinely washing their hands between farms and those that reported washing their hands after contact with potentially infectious cases had a significantly lower rate of MRSA carriage. That should come as absolutely no surprise, but it's one more piece of evidence that we need to pay more attention to this routine infection control measure, in human hospitals, in veterinary environments and in households.
Remember, the 10 most important sources of infection are the fingers on your hands!
Click here for instructions on how to wash your hands properly.
