Animals Visiting Healthcare Facilities

Animals Visiting Healthcare Facilities

What are the key concepts related to Animals Visiting Healthcare Facilities? 

Animals may be present in healthcare (AHC) for multiple reasons and their presence has increased in acute care hospitals and ambulatory medical settings. According to the Humane Society of the United States, pet ownership is common in the United States with 65% of US households reported including a pet; dogs and cats represented over 70% of household pets (dogs 40%, cats 32%, respectively).

Patients in healthcare facilities come into contact with animals primarily through the use of animals for animal-assisted activities (animal-assisted activities encompass “pet therapy,” “animal-assisted therapy,” and pet volunteer programs) and the use of service animals such as guide dogs for the sight impaired. Other reasons for contact with AHC include the use of animals in research, and personal pet visits to their owners in the hospital (personal pet visitation). Finally, animals may occasionally be used in healthcare facilities for other medical reasons, such as medicinal leeches and larva debridement therapy, educational purposes (e.g., zoo and farm animals), and decorative purposes (e.g., aquariums).

Risks to patients from exposure to animals in the healthcare setting may be associated with transmission of pathogens through direct or indirect contact or, less likely, droplet/aerosol transmission (See Table I). However, insufficient studies are available to produce generalizable, evidence-based recommendations and as a result, substantial variations exist in policies and practice across healthcare institutions. This chapter is condensed and updated from the SHEA Guidance Document “Animals in healthcare facilities: recommendations to minimize potential risks” and from a recent book chapter (Murthy RK, et al. 2017). Healthcare facilities should develop clear policies and practices related to animals to ensure the safety of patients, visitors, healthcare personnel (HCP), as well as that of the animals. 

Table I.

What principles need to be adhered to related to Animals Visiting Healthcare Facilities for effective infection control?

Healthcare facilities considering programs allowing animals develop and implement policies that include well-organized communication and education directed at HCP, patients, and visitors, for each of the major applicable categories: animal-assisted activities, service animals, research animals, and personal pet visitation. 

Although little published literature exists on this topic, the Society of Healthcare Epidemiology of America has recently issued an expert guidance document with specific recommends on the management of AHC in four categories as defined below (Table I represents a summary of key recommendations): 

• Animal-assisted activities (AAA): While these practices and their purposes may vary because these animals and their handlers are (or should be) specifically trained, they will be referred to as animal-assisted activities animals in this document.

• Service animals: specifically defined in the US under the Americans with Disabilities Act (ADA) 

• Research animals: animals approved for research by the facility’s Institutional Animal Care and Use Committee (IACUC) 

• Personal pet visitation: defined as a personal pet of a patient that is brought into the facility specifically to interact with that individual patient.

Key principles that should be outlined in policies and followed include:

• Defining categories and types of animals permitted 

• Specify ADA compliance requirements for service animals  

• Oversight of AHC program and activities 

• Minimal criteria for safe management of AHC

• Training and health requirements for animals and handlers

• Documentation of animal visits and contact tracing

• Preparing animals for visits or criteria for discontinuing visits

• Transportation of animals 

• Locations or conditions where animals are not permitted 

• Environmental control (animal hygiene, cleaning, waste disposal)

What are the key conclusions for available clinical trials or meta-analyses related to Animals Visiting Healthcare Facilities that guide infection control practice and opinion?

Scientific studies addressing the potential risks of animal to-human transmission of pathogens in the healthcare setting are limited in number and, because animals have generally been excluded from hospitals, the experience gained to date has been mainly from case reports and outbreak investigations. For example, human strains of methicillin-resistant Staphylococcus aureus (MRSA) have increasingly been described in cats, dogs, horses, and pigs, with animals potentially acting as sources of MRSA exposure in healthcare facilities. MRSA is just one of many potential pathogens; a wide range of pathogens exist, including common healthcare-associated pathogens (e.g., Clostridium difficile, multidrug-resistant enterococci), emerging infectious diseases (e.g., extended spectrum β-lactamase (ESBL)– producing Enterobacteriaceae), common zoonotic pathogens (e.g., Campylobacter, Salmonella, and dermatophytes), rare but devastating zoonotic pathogens (e.g., rabies virus), and pathogens associated with bites and scratches (e.g., Pasteurella spp., Capnocytophaga canimorsus, and Bartonella spp.).

What are the consequences of ignoring key principles and concepts?

Exposure to animals can result in transmission of pathogens to patients, visitors and HCP through direct or indirect contact or through droplet/aerosol transmission (See Table II). Substantial variation exists in policies and practices across healthcare institutions related to animals, which can lead to inconsistent application of key principles of infection prevention; for example, healthcare facilities must follow the federal legal requirements as outlined in the ADA and educate HCP regarding legal rights for persons with service animals and the minimum access required by law. 

Table II.

Table III.

Difference between AAA and Service animals: 

Animal-assisted activities animals and their handlers are trained to provide specific human populations with appropriate contact with animals. They are usually personal pets of the handlers and accompany their handlers to the sites they visit, although animal-assisted activities animals may also reside at a facility. AAA animals must meet specific criteria for health, grooming, and behavior, and their access can be restricted at the discretion of the facility. AAA animals are not service animals. Federal law, which protects the rights of qualified persons with disabilities in terms of service animals, has no provision for AAA animals.

What other information supports the key conclusions of studies of or advice from Animals Visiting Healthcare Facilities e.g., case control studies and case series?

Until more definitive information is available, healthcare facilities should establish policies to prioritize patient and HCP safety, and to use standard infection prevention and control measures to prevent animal-to-human transmission in healthcare settings.

Summary of current controversies regarding Animals Visiting Healthcare Facilities.

Current controversies related to AHC include the following and are described in detail below:

• Benefits of AAA 

• Animals providing emotional support 

• Role of cats in AAA

• Research animals

• Personal pet visitation in healthcare facilities

• Medicinal leeches

• Maggot debridement therapy

• Aquariums

• Petting zoos

Current controversies related to Animals Visiting Healthcare Facilities

Benefits of animal assisted therapy

Multiple studies have demonstrated benefits of AAA including enjoyment of canine-assisted ambulation for patients with heart failure (hospital), decreased loneliness (long-term care), improved social functioning (psychiatric ward), decreased fear and anxiety in electroconvulsive therapy (hospital), reduces anxiety in psychiatric patients (hospital), improved nutritional uptake in Alzheimer’s disease with contact with fish aquariums, improved depressive symptoms in patients with dementia, depression or psychosis (nursing home), and decreased perceived pain in children (pediatric hospital). However, the benefits of AAA in general hospitalized patients have not been adequately assessed in high quality comparative trials.  

The general risks of animals in the hospital have been described above. Additional concerns regarding AAA, especially for immunocompromised patients or patients with host defects include local infection or seeding of proximal prosthetic joints following licks by a dog, and peritonitis in patients with peritoneal dialysis catheters.  

Animals providing emotional support

Human-animal interactions have been reported to have physical (e.g., lower blood pressure) and social (e.g., improved self-esteem, reduced levels of stress, reduced anxiety) benefits. However, because most of the studies were uncontrolled and compared pet owners with non-pet owners, substantial bias and/or confounding may have been present in the studies. Indeed, there have been few controlled studies that provide empirical evidence of positive physical or mental health outcomes associated with interactions from companion animals. 

The risks associated with the use of animals in healthcare facilities to patients, visitors and HCP have been described above and include physical injuries (e.g., bites and scratches), allergies, and zoonotic infections. Importantly, emotional support animals are unlike service animals in that there are strict criteria that define a service animal (i.e., ability to perform work) that can be observed while there are no strict observable criteria that define an emotional support animal. Thus, a healthcare facility that allows the use of emotional support animals might find a large number of patients and visitors requesting the use of such animals with an increased risk of physical injuries, zoonotic infections and/or precipitating allergies. Adoption of the Fair Housing Act standards would also permit the use of a variety of animals (e.g., primates, birds, etc.) that may increase the risk of injuries and zoonotic infections and preclude requirements for training or certification of the animal.

Role of cats in AAA

Though more households have dogs than cats (36.5% vs 30.4%), the total number of domestic cats (approximately 74 million) in the United States is higher than the number domestic dogs (approximately 70 million), as the average number of cats owned per household is higher than of dogs; in addition, although less studied than dogs, some studies suggest that cats improve the well-being of older adults.

Cats may be source of many infectious diseases transmitted to humans by bites, scratches and licks (e.g., P. multocida); direct contact (e.g., MRSA); fecal-oral transmission (e.g., toxoplasmosis); inhalation (e.g., Q fever); or via ectoparasites. Pasteurella multocida is the most common pathogen isolated from cat bite or scratch related infections, most commonly causing a rapidly evolving cellulitis. Though a variety of other pathogens may also be transmitted by cats (e.g., Bartonella), recent studies have also demonstrated that methicillin-resistant Staphylococcus aureus (MRSA) may colonize companion animals including cats which may be transmitted to humans. Cats are not recognized under the ADA as approved service animals.

Cats, in general, should not serve as an AAA animal. This is because of their temperament (i.e., bite or scratch moving objects); lesser ability to be trained compared to dogs; multitude of potential pathogens that they can transmit via direct contact, bites or scratches, inhalation, fecal-oral exposure, or indirect exposure (i.e., ectoparasites); occasional reports of nosocomial outbreak associated with cats; and lack of protocols for safe use as AAT animals. For similar reasons, cats should, in general, not be allowed in hospitals for “pet” visits. Exceptions for a single “pet” visit may be considered for terminal patients on compassionate grounds to say goodbye to their pet cat under strict supervision and with the approval of the patient, the attending physician, and infection prevention. 

Research Animals

The advancement of human health through research in basic science as well as clinical and translational science often requires the application of sophisticated equipment and clinical techniques for research animals. Many health-science centers may not be able to dedicate some equipment items and facilities solely for animal use due to the logistics and expense associated. Therefore, healthcare institutions may need to consider using equipment and facilities used for humans to also study research animals. In addition, zoos and veterinary facilities may also appeal to human healthcare facilities to diagnose or treat sick or injured animals. 

Animals can serve as a reservoir and vehicle for potentially infectious pathogens; as such, potential pathogens can be transmitted from research animals to humans. Though the focus of this document is on transmission of infectious agents, given the variety of animals that may be used in research settings, it should be noted that some animal species may pose additional threats, such as physical injury from large animals or envenomation. 

Potential routes of inoculation and the range of pathogens associated with research and veterinary animals include: Direct inoculation from percutaneous or mucosal membrane exposure, inhalation, direct contact, fecal-oral, and indirect transmission via vectors (such as ectoparasites). Finally, transmission via indirect contact may occur as animals may be infected with prions, leading to potential risk for transmission via surgical instruments or medical devices if the same instruments are subsequently used on humans. 

In order to accommodate these situations, where applicable, acute care hospitals should establish comprehensive policies and procedures in order to ensure patient and public safety, while enabling safe, effective, and efficient evaluation and treatment of animals. Particular attention must be paid to animal transport, environmental cleaning as well as to use of dedicated medical devices and instruments for animals. 

Pet visitation in healthcare facilities

Visitation of patients in healthcare facilities by their own pets potentially offers benefits and challenges. While pets are less scrutinized and would not necessarily fulfill the requirements for AAA visitation programs, the potentially strong human-animal bond and corresponding potential positive impact on the patient leads many facilities to permit this activity. The pre-established relationship between pet and person could reduce the risk of adverse events such as bites and scratches. However, pets and their owners typically do not undergo the same (or any) form of training and scrutiny as compared to animal-assisted activities teams. Pets do not typically undergo the same degree of health assessment or exclusion practices (e.g., age) as compared to animals used in AAA. Further, while visitation with pets may be restricted to an individual patient, in practice the pets may encounter various healthcare workers, visitors, and patients during their time in the facility. Additionally, pets have typically not been temperament tested, resulting in inconsistency in their behavior in an unfamiliar healthcare environment. For these reasons, pet visitation in general should be prohibited from healthcare facilities, except for special circumstances (such as compassionate reasons). Finally, if pets are allowed, as with AAA, only dogs should be considered and only under specified circumstances and with close supervision; cats should not be allowed for the reasons stated above in AAA.

Medicinal Leeches

Medicinal leeches are used in modern medicine to sustain circulation in the management of acute venous congestion in patients with replantation of digits and ears and in reconstruction using cutaneous or muscle flaps. Evidence has also demonstrated that leeches might provide therapeutic pain reduction in patients with osteoarthritis. Leech therapy most commonly uses Hirudo medicinalis and usually lasts around 2-6 days. Leeches may remove 5-15 mL of blood in this period to prevent congestion, keeping the tissue perfused until venous capillary return is established. Leech saliva released during feeding contains biologically active substances that act as vasodilators, anti-inflammatory mediators, anticoagulants, and analgesics. The most important component of leech saliva is the anticoagulant and bactericidal agent hirudin.

Leech therapy (hirudotherapy) is generally considered safe and well-tolerated, but contraindications include arterial insufficiency, hematologic disorders, and allergy to leeches. Infection is a major complication and has been reported with Aeromonas hydrophila (a common pathogen found in the gut of leeches that has been implicated in an incidence of sepsis after leech therapy) as well as with Vibrio fluvialisand Serratia marcescens. Other potential complications following hirudotherapy include thrombotic microangiopathy, anemia, and continued bleeding.

Antimicrobial prophylaxis with trimethoprim-sulfamethoxazole or ciprofloxacin appear to be equally effective for prevention of leech-associated infection of Aeromonas spp. However, antibiotic resistant Aeromonas hydrophila infection following leech therapy has been reported. Guidelines for using leeches include general storage protocols (in a refrigerator or cool, dark place in a glass or plastic container with bottled or distilled, non-chlorinated water as well as a salt additive). Tap water, direct sunlight, and temperatures above 20oC are contraindicated for leech storage. Used leeches should never be reused even on the same patient or returned to the pharmacy. They should be disposed of as regulated (i.e., hazardous) medical waste.

Maggot debridement therapy

Larval debridement therapy, also known as maggot debridement therapy (MDT) uses sterile larva of the fly Lucila sericataand is implemented around the world to treat wounds that are resistant to conventional therapy. Maggots preferentially digest and remove necrotic tissue, leaving behind healthy tissue. Antimicrobial and anti-inflammatory properties of MDT therapy also aid in wound healing through disinfection and tissue growth stimulation.

MDT has been shown to effectively treat chronic ulcers in diabetics and wounds in patients with malignancies. The most common complaint after MDT in patients is pain due to the hook-like teeth of maggots used for locomotion, but it can be controlled with analgesics. While many clinical uses for MDT have been identified, contraindications include dry wounds, wounds close to large blood vessels, and patients allergic to fly larvae.

Before the use of larvae, external disinfection of the fly eggs is necessary to reduce the chance of introducing new bacteria into the wound. Used maggots should be disposed of as regulated (i.e., hazardous) medical waste (i.e., placed in a tight fitting bottle) and incinerated.  

Aquariums/Fishtanks

While aquariums and fish tanks are found by many to be visually appealing, infections pose a serious concern. M. marinum infections have been shown to be associated with cleaning fish tanks. Aquariums have been associated with outbreaks of infections due to Salmonella paratyphi and Legionnaires’ disease.

Because fish tanks can be a reservoir for many pathogens, fish tanks should be generally excluded from healthcare facilities, including non-clinical areas; however, aquariums may be permitted if maintained by trained personnel, utilize a closed system, and are implemented with water pumps designed to prevent aerosalization. Patients should never have direct access to the aquarium.  

Petting Zoos

Animal exhibits such as petting zoos provide a popular, managed learning environment that involve interaction with animals such as feeding and other physical contact. Conrad et al. compiled a review of the principal causal organisms of human illness associated with petting zoos and farm environments that includes Campylobacter, non-0157 Shiga toxin-producing Escherichia coli(STEC), Yersinia enterocolitica, Salmonella, and Cryptosporidium.

Transmission risk of enteric infectious diseases and parasites may be higher in children where high-risk behaviors may contribute to pathogen transmission, such as contact with manure and hand-to-mouth behaviors such as thumb sucking. Controlling transmission is difficult as livestock can shed pathogens such as E.coliO157:H7 intermittently, can shed due to stress from confinement, transport, and human interaction, and can carry infectious organisms in their fur, saliva, and hair due to fecal contamination. Additionally, nontyphoidal Salmonella species are found in live poultry including baby chicks and ducklings. Lastly, infections spread to humans from pet reptiles have been identified, with 90% of captive reptiles estimated to carry Salmonella.

As petting zoos and other animal exhibits have been associated with infectious outbreaks, such environments should be prohibited from healthcare facilities. If any exceptions are made for special situations, they should not be conducted as an activity of the healthcare facility to avoid confusion about the healthcare facility’s responsibility for legal and regulatory requirements.

What National and International guidelines exist related to Animals Visiting Healthcare Facilities?

The most current guidance on AHC is reflected in the 2015 SHEA expert guidance document entitled “Animals in Healthcare Facilities: Recommendations to Minimize Potential Risks”, which outlines a set of practical recommendations on this topic based on current knowledge and expert opinion from experts in infectious diseases, infection control and prevention, veterinary medicine, and legal issues and endorsed by SHEA and the Association for Professionals in Infection Control and Epidemiology (APIC). The document describes standard infection prevention and control guidance to help protect patients and healthcare providers from the spread of pathogens via animal-to-human transmission in healthcare settings. The recommendations were based on available evidence, practical considerations, survey findings of SHEA members, writing group opinion and consideration of potential harm where applicable.

Key recommendations for each of the 4 categories are included below and summarized in Table I:

Animal-Assisted Activities 

• Facilities should develop a written policy for animal-assisted activities. An animal-assisted activity visit liaison should be designated.

• Allow only dogs to serve in AAA. 

• Animals and handlers should be formally trained and evaluated.

• Animal interaction areas should be determined in collaboration with the Infection Prevention and Control team and clinical staff should be educated about the program. 

• Handlers must have all required immunizations, restrict contact of their animal to patient(s) visited and prevent the animal from having contact with invasive devices, and require that everyone who touches the animal to practice hand hygiene before and after contact.

• The hospital should maintain a log of all animal-assisted activities visits including rooms and persons visited for potential contact tracing.

Service Animals

• The policy allowing service animals of patients and visitors into the facility should be compliant with the Federal Americans for Disability Act (ADA), any other applicable state and local regulations and include a statement that only dogs and miniature horses are recognized as Service Animals under federal law.

• If an inpatient has a service animal, notification should be made to the Infection Prevention and Control Team, followed by discussion with the patient to make sure the service animal complies with institutional policies.

• Healthcare providers or staff may ask the patient or visitor to describe what work/tasks the dog performs for the patient, but may not ask for a “certification” or “papers.”

Research Animals 

• After a protocol is established by the Institutional Animal Care and Use Committee, the investigator should work with the appropriate clinical area to schedule procedures to minimize the potential for animal contact with patients or the public.

• Animals must be transported to and from clinical areas in an enclosed, escape-proof container.

• Use of disposable equipment is highly desirable. Alternatively, instruments dedicated to animal use should be used but should ideally be disinfected or sterilized separate from human instruments.

Personal Pet Visitation

• Pets should, in general, be prohibited from entering the healthcare facility.

• Exceptions can be considered if the healthcare team determines that visitation with a pet would be of benefit to the patient and can be performed with limited risk. Even then, visitation should, in general, be restricted to dogs.

• The patient must perform hand hygiene immediately before and after contact with the animal.

What other consensus group statements exist and what do key leaders advise?

Previous guidelines that have covered some of the issues on this topic include the 2008 Association for Professionals in Infection Control and Epidemiology (APIC) “Guidelines for animal-assisted interventions in healthcare facilities” and the 2003 “Centers for Disease Control and Prevention (CDC)/Healthcare Infection Control and Prevention Advisory Committee (HICPAC) Guidelines for Environmental Infection Control in Health-Care Facilities.” The 2015 SHEA expert guidance document, entitled “Animals in Healthcare Facilities: Recommendations to Minimize Potential Risks”, provides an update to the previous documents and outlines a set of practical recommendations on this topic based on current knowledge and expert opinion from experts in infectious diseases, infection control and prevention, veterinary medicine, and legal issues and endorsed by SHEA and the Association for Professionals in Infection Control and Epidemiology (APIC). The document describes standard infection prevention and control guidance to help protect patients and healthcare providers from the spread of pathogens via animal-to-human transmission in healthcare settings.

The guidelines note that as the role of animals in healthcare evolves, there is a need for stronger research to establish evidence-based guidelines to manage the risk to patients and healthcare providers.

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