H1N1 - Good reason to stay home!

The AVMA recently reported H1N1 influenza virus infection in a group of ferrets at a veterinary hospital in Erlanger, KY.  Within two days of an older ferret becoming ill with severe pneumonia, 16 other ferrets showed signs of lethargy, sneezing, coughing and nasal discharge.  A pharyngeal swab from one of the ferrets tested positive for 2009 H1N1.  Prior to the illness in the first ferret, one of the staff members at the hospital had been ill with mild flu-like symptoms, but no reported fever.  Other pet cases of confirmed H1N1 have been reported in cats and dogs, usually following illness in a human family member.  As veterinarians, we should be aware of the potential for the zoonotic spread of H1N1, especially from us and our staff to our patients.

Transmission
The primary route of H1N1 influenza virus transmission is by droplet (aerosol) transmission, i.e., infected droplets propelled from the cough or sneeze of an infected individual contact the nose or mouth of a susceptible individual.  The virus can also spread either by direct contact between infected and susceptible individuals, e.g., hand-to-hand or nose-to-nose contact.  Because the virus can live for up to 48 hours on environmental surfaces, indirect contact, i.e., contact with a contaminated object (fomite transmission), is also a potential source of infection.  Airborne transmission, e.g., from aerosols generated during procedures such as intubation, suctioning, bronchoscopy, nebulizer treatment or similar procedures, is also a concern for risk of transmission.  It is not known if other routes, such as ocular, conjunctival or gastrointestinal infections can occur.

Clinical Signs
The clinical signs of H1N1 in pets resemble most other viral respiratory infections in both people and in animals, i.e., coughing, sneezing, ocular and/or nasal discharge, and possibly fever, lethargy, loss of appetite, and respiratory abnormalities (e.g., dyspnea, tachypnea). 

Infection Control Measures
In general, standard precautions that limit the spread of any disease by the aerosol, direct contact or indirect routes of transmission will be effective in reducing the risk of H1N1 transmission.  Standard precautions begin with the reception staff, all of whom should be trained to take a minimal history at the time clients book an appointment so that any animal exhibiting signs of respiratory disease are identified prior to the visit.  If there is a separate entrance to the animal care facility for infectious patients, owners should be instructed to bring their pet through that entrance for check-in. To avoid exposing other animals and their owners, these animals should be taken directly to an exam room upon arrival, preferably one that has been dedicated for the intake and examination of animals with suspected infectious disease.  If this is not possible, clients may be asked to wait outside, preferably in their vehicles and away from the hospital entrance, until an exam room is available.  In general, all clients should be advised to restrain their pets while in the reception area to help minimize the risk of any infectious disease transmission.  Signs can be posted in the reception area to gently remind clients of their important role in helping prevent the transmission of infectious diseases. 

When handling animals with respiratory disease, all personnel should wear appropriate protection, i.e., gloves, mask, eye protection and protective outwear.  All respiratory secretions and bodily fluids (including ocular discharges and feces) of suspected H1N1 influenza cases should be considered potentially infectious. Full facial protection is especially warranted if any aerosols, splashes or sprays are anticipated, e.g., via intubation, suctioning, bronchoscopy, transtracheal or bronchial washings, nebulizer treatments or similar procedures.  After completing the examination or treatment, gloves and masks should be removed and disposed of properly.  Hands should be thoroughly washed (or disinfected with an alcohol-based hand rub if soap and water are not available) to remove any potential contaminating organisms.  All instruments and equipment that have come in contact with the patient or the contaminated hands of veterinary personnel should be considered infectious and handled as such.  Likewise, protective eyewear, face shields and soiled protective outwear should be removed, handled as contaminated items, and cleaned and disinfected, disposed of or laundered appropriately.

When performing necropsies on patients with known or suspected H1N1, standard personal protection is required, i.e., gloves, facial protection, impermeable protective outer wear, and cut-proof gloves.  If aerosols will be generated, e.g., use of a band saw or other power equipment, an appropriate respirator should also be worn.   Only essential personnel, who are adequately protected, should be present during necropsy.  Protective outwear and disposable gloves should be worn when handling all diagnostic specimens.  All specimens should be packaged and labeled appropriately as infectious material prior to shipping.

Routine cleaning and disinfection precautions should be rigorously enforced during the influenza season.  Any area that has been occupied by an infected animal should be thoroughly cleaned and disinfected prior to allowing other animals into the area.  This includes cleaning and disinfecting any surface that may have been contaminated, including the exam table, counter tops, floor, chairs, etc.  The Environmental Protection Agency lists 500 disinfectants with 50 different active ingredients that are active against H1N1.  When selecting a disinfectant, the EPA recommends that one select “…a product whose label states that it is effective against "Influenza A virus" and lists your specific site of concern, such as: farm premises, hospitals and other healthcare facilities, schools, offices or homes”.  Three commonly used disinfectants that are effective against H1N1 when used at the appropriate dilution include: bleach diluted to 10% in water, ethanol diluted to 70% in water, and Lysol diluted to 5% in water.  Wear clean gloves during the cleaning and disinfecting process. Wash or disinfect hands after completing the process and removing gloves.

Prevention
Because H1N1 infection is potentially fatal in humans and in animals, prevention is critically important.  Most of us are familiar with the common-sense prevention measures, including the advice to: 1) stay home when ill with flu-like symptoms, 2) wash hands frequently, 3) cover one’s mouth and nose when coughing and sneezing, 4) keep hands away from one’s face, and 5) avoid close contact with sick people (within 6 feet).

Similar precautions can be recommended to our clients when they become sick with influenza-like symptoms to help them avoid infecting their pets.  In addition, we can recommend that our clients with susceptible food or zoo animals practice and enforce heightened biosecurity measures to avoid the zoonotic transmission of H1N1 among staff and animals.  These include:

1) Avoid introducing new animals to the herd, flock or exhibit.

2) If you must acquire new animals, do so only from trusted sources.  Quarantine any new arrivals before introducing them to the herd or flock.

3) Use only your own equipment.  Disinfect equipment between animal groups.  If you must borrow or lease equipment, disinfect it prior to use, then again after use. 

4) Allow only essential personnel to enter the animal site.

5) Ensure that all workers disinfect their shoes, clothes and hands prior to entering and leaving the work place.

6) If workers are ill with influenza-like symptoms, encourage them to stay home.  If this is not possible, require them to wear a mask in addition to their usual protective wear when working with the animals.

7) Train workers to recognize and report signs of respiratory illness in the herd or flock.

As veterinarians we have an important role to play in preventing the spread of H1N1 by adopting and enforcing standard precautions in our own practice settings.  We are equally responsible for educating our clients in the importance of preventing the spread of H1N1 and in seeking veterinary medical attention if their animals present with suspect respiratory symptoms, especially if another pet or family member has been ill with influenza-like symptoms.

 

Resources

AVMA.  2009 H1N1 Flu Virus Outbreak.  Updated March 7, 2011

http://www.avma.org/public_health/influenza/new_virus/default.asp

 

AVMA.  Frequently Asked Questions by Veterinarians about 2009 H1N1 Flu Virus.  Updated February 14, 2011

http://www.avma.org/public_health/influenza/new_virus/new_flu_virus_faq_veterinarians.asp

 

U.S. Environmental Protection Agency, Antimicrobials Division.  Antimicrobial Products Registered for Use Against Influenza A Virus on Hard Surfaces Office of Pesticide Programs.

http://www.epa.gov/oppad001/influenza-a-product-list.pdf

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