Guidelines for pet therapy

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•  Guidelines for pet therapy
• in long-term care

Sandi Lefebvre DVM, PhD American
Veterinary Medical Association
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Protocol

• Understand whats at stake
• Identify potential problems
• Identify potential solutions
• Take-home message

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Protocol

• Understand whats at stake
• Identify potential problems
• Identify potential solutions
• Take-home message

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What do I mean by pet therapy?

• Any intervention that intentionally includes or
  incorporates animals as part of a therapeutic or
  ameliorative process or milieu. (Kruger
  Serpell, 2006)

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What are the benefits?

• Diversion from treatments and pain
• Nonjudgmental affection
• ? anxiety
• ? stress
• ? activity

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Where can therapy dogs come from?
of Ontario hospitals
(Lefebvre et al, Infect Control Hosp Epidemiol
200627754-8)
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Protocol

• Understand whats at stake
• Identify potential problems
• Identify potential solutions
• Take-home message

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What are some potential risks?
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What can get transmitted?
Animals can be carrying pathogens without
showing clinical signs

• Traditional zoonotic pathogens
• Salmonella
• Gastrointestinal parasites
• Emerging zoonotic pathogens
• MRSA
• C. difficile?
• Nonzoonotic pathogens
• Influenza? Norovirus?

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Issues with healthy animals
Prevalence of potentially zoonotic pathogens in
HEALTHY, vaccinated visitation dogs in Ontario
(n102)
of dogs testing positive
Pathogens
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If pets dont bring it in, they can still carry
it out

• Specific evidence
• Dogs that visit LTC facilities are
• 6x as likely to acquire MRSA than dogs that dont
• 2x as likely to get C. difficile

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Do we know how dogs pick up pathogens?

• MRSA
• Licking ? 13x as likely (p 0.002)
• Fed treats by patients ? 12 times as likely
  (p 0.005)
• No association with
• Coprophagia
• Drinking from toilets
• Sitting on beds

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Do we know how dogs pick up pathogens?

• C. difficile
• Licking ? 3x as likely (p 0.020)
• Sitting on beds ? 3x as likely (p 0.032)
• No increased risk with
• Coprophagia
• Drinking from toilets
• Being fed treats

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Theres more

• Specific evidence
• Dogs that eat raw diets are 20x as likely to
  shed Salmonella or multidrug-resistant E. coli
  than dogs that dont
• Dogs can acquire MRSA on their fur or C.
  difficile on their paws during visits

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How else can pathogens spread?

• Observation of 26 pet therapy visits
• Neither healthcare workers nor patients practice
  hand hygiene after handling dogs
• Handlers very rarely practice hand hygiene
  between patients

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Theres more

• Some opportunities for improvement in HCFs
• Appears to be a disconnect between what hospitals
  believe is going on and what actually happens

• Poor opportunities for contact tracing Only
  8/12 hospitals and 4/14 LTCs required signing in

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Protocol

• Understand whats at stake
• Identify potential problems
• Identify potential solutions
• Take-home message

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Challenges to designing standard guidelines

• Limited information available to determine how
  real the risks are
• Different geographic regions (or facilities) mean
  different risks for different pathogens
• Different facilities have patients of varying
  immune status, mobility, degree of interaction
  with other patients.

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Challenges to implementing guidelines in LTCs

• Patients may not be confined to rooms
• Facilities may be understaffed
• Animals may visit many wards with different
  patient demographics
• May be more difficult to determine sources of
  infections

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1 Practice hand hygiene

• Patients
• Healthcare workers (ALL!)
• BEFORE and AFTER handling animals
• Dog handlers
• In accordance with facilitys policies
  for staff/volunteers

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2 Have facility management of programs

• Develop a written policy for animal visits
• Designate one individual responsible for keeping
  track of visits (Animal Visit Liaison)

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3 Specify suitable animals

• Keep out
• Freelance animals
• Limited screening (if any)
• Handlers are rarely trained
• Shelter animals
• Pathogen-rich environment
• Temperament potentially unpredictable
• Unknown histories (Ont Dis Surveil Rep 1986)

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3 Specify suitable animals

• Keep out
• High risk species
• Farm animals (Steinmuller et al, 2006)
• Reptiles amphibians (Yamauchi et al,
  1984) (www.cdc.gov/healthypets/child.htm)
• Animals recently domesticated
• Hedgehogs (Riley Chomel, 2005)
• Prairie dogs (Kile et al, 2005)
• Wild animal crosses
• Animals from the wild

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Some species are riskier than others
Novelty should not guide decisions
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3 Specify suitable animals

• Allow both official program animals and patients
  animals
• For patients animals
• Household pets only
• No age restriction
• Visit patient only

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3 Specify suitable animals

• For program animals
• Must be part of formal program
• Require temperament testing

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Require temperament testing

• By qualified evaluator
• Encounter challenges typical of facility visited
• Reevaluation?
• Negative behaviour
• Change in health
• Prolonged absence
• Every 3 yrs?

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3 Specify suitable animals

• For program animals
• Must be part of formal program
• Require temperament testing
• Specify minimum age
• Specify suitable species

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3 Specifying suitable animals

• For all animals
• Legally required vaccines (rabies)
• Healthy on day of visit
• No raw meat within 90 days
• For program animals
• Health evaluation at least once/yr
• Defer to veterinarian for other needs

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4 Ensure handlers are trained and managed
appropriately

• Require that handlers of patients animals be
  escorted to patient
• Require that handlers of program animals
• Be trained
• Comply with facility IPC
  protocols for volunteers
• Be in control of animal at all
  times
• NO EATING!!

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5 Ensure animals are prepared for visits

• Require that handlers ensure
• Proper grooming
• No fleas/ticks
• Clean leash/carrier
• Either on leash at all
  times or in carrier between
  rooms

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6 Ensure appropriate contact

• Prevent program animals from entering ICUs or
  isolation
• Have handlers prevent contact of animals with
  sites of invasive devices or open wounds

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6 Ensure appropriate contact

• Require that handlers
• Prevent animals from licking
• Deter shaking of paws
• Use barrier methods when placing animals on beds
• Limit visits to 1 hour maximum

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7 Monitor whos coming in

• One person responsible for knowing (a.k.a. Animal
  Visit Liaison)
• Record-keeping ? contact tracing
• Reporting system for problems

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Protocol

• Understand whats at stake
• Identify potential problems
• Identify potential solutions
• Take-home message

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Take-home message

• Pet therapy is good for patients
• We dont know if it can make patients sick
• I suspect it does make some pets sick
• Recommendations should minimize most risks to
  both parties
• Keeping records will create extra work, but will
  be worth it!