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Handling Clinical Samples
 

Copyright 2007, University of Minnesota Board of Regents.

The University of Minnesota is an equal opportunity educator and employer.

Nonhuman Primate Biosafety

In June 2003, "Occupational Safety and Health in the Care and Use of Non-Human Primates" was published. This report covers topics particularly relevant to facilities in which nonhuman primates are housed or where nonhuman primate blood or tissues are used. The report is available at http://www.nap.edu/catalog/10713.html. The report describes the hazards associated with work involving nonhuman primates and discusses the components of a successful Occupational Health and Safety Program, including hazard identification, risk assessment, applicable safety regulations, risk management, and personnel training. Topics include techniques for assessing the degree of risk for those hazards, options for managing those risks, worker training, and personal protective equipment; institutional management of workers after suspected exposures; and examples of safety and health programs in both large and small nonhuman primate facilities.

Zoonotic Disease

Cercopithecine Herpes Virus I

Most species of macaque monkeys (rhesus, cynomolgus, pigtail) can carry a virus known as B virus, Herpesvirus simiae or Cercopithecine Herpes Virus I. It is very similar to human herpes virus which causes cold sores in humans. In the monkey, the virus causes simple cold sores.  In the monkey, the virus usually does not cause disease, but in humans it causes a brain infection (encephalitis) that is fatal in over 85% of cases.  Infection in humans is rare, but most cases have involved contact with nonhuman primates. Immediate diagnosis and treatment with antiviral drugs has saved lives. The procedure outlined below is adapted from recommendations from the Centers for Disease Control and has been shown to reduce the risk of contracting Herpes B in the event of a bite or other wound, or an exposure to mucous membranes or broken skin.

Since B virus has a high prevalence in conventional primate colonies, and animals can carry the disease without showing symptoms, it is best to assume that all primates are infected.  Body fluids such as saliva and urine present the highest risk to workers.  Caretakers are at special risk, since routine care and cage washing involves frequent contact with sharp edges on contaminated cages and production of aerosols from spraying animal waste.  In laboratories, activities such as pipetting, opening containers and centrifuging urine, blood or mucosal swabs can present risk of contamination.  Use of protective clothing, eye protection and respiratory protection are essential.  Consistent caution and respect for the monkey is always a good idea.  In addition, if you ever spot what looks like a cold sore on a monkey, be sure to contact RAR before handling the animal or its cage.

[Link to Website on Prevention of Herpes B infection]
 

Bite, Splash, Scratch

Procedures to Follow in Case of Contact with Body Fluids from a Nonhuman Primate (Rhesus or cynomolgus only)

1. REMAIN CALM. Nothing happens so quickly that you can't take a breath and assess the situation. IF you have one of the following:
• A bite or scratch that causes bleeding
• A cage scratch that causes bleeding
• A puncture by a needle (that was used on a rhesus or cynomolgus monkey)
• Splashing of feces, urine, saliva or blood into your eye or mouth or a cut or open area in your skin.

THEN follow the procedures below:

2. Open the sealed packet containing the scrub brush and soap. Wet the brush and scrub the wound for 15 minutes using the bristles, not just the sponge side. This may be painful, but will greatly reduce the risk of a life-threatening infection. For an eye splash, rinse your eyes at the eye wash station for 15 minutes.
   
   
3. Swab the wound deeply, if you can, using one of the viral culture swabs. Do not swab your eyes. Place the swab in the vial containing the viral transport media, break off the end of the swab shaft and tightly seal the screw cap. Place the specimen in a biohazard transport bag and seal.
   
   
4. Go directly to Boynton Health Service Urgent Care (625-8400) during business hours. Boynton's hours are: Mondays 8:00 a.m. to 6:00 p.m. and Tuesday through Friday 8 a.m. to 4:30 p.m. Take your swab with you as well as this two-sided sheet marked "NHP Bite, Splash, Scratch Protocol". Go directly to Boynton Health Service and report to the main check-in appointment desk. Do not wait in line but instead go directly to the receptionist at the check-in desk and report that you had an exposure to a non-human primate and you are here to be seen in urgent care now.

When Boynton is closed go to the Fairview-University Hospital emergency room. When possible a co-worker should call the emergency room ahead of time (612 273-2700) and tell a physician or nurse the nature of the exposure.

5. Call RAR at 612 624-9100 and/or page the on-duty veterinarian as soon as possible after the exposure. It is important that the monkey be sedated and tested for Herpes B virus. Also, the animal care supervisor can be contacted on weekends until 1 PM at 624-6169 (until 1 p.m.), or by paging 8-527-3853.
   
   
6. File a First Report of Injury form with your Departmental administrator as soon as you are able.

Information for Boynton Health Regarding Non-Human Primate Bites, Scratches or Splashes onto Mucous Membrane (Macaque Species)

1. Confirm that the wound is related to a macaque species (Rhesus and cynomolgus monkeys are currently used. The only non-macaque species currently being used is baboon). For a wound inflicted by a non-macaque, follow normal animal bite procedures. Boynton Health Service staff should refer to Detailed Health Care Provider Protocol for Exposure to Nonhuman Primates (macaque species).
2. Confirm that Research Animal Resources (RAR) has been contacted (phone number 612-624-9100). RAR is responsible for obtaining swabs and serum samples from the animal involved and for submitting these samples for testing.
3. Assess adequacy of prior cleaning. If there is any doubt that the wound was cleaned thoroughly for a full 15 minutes, clean the wound again for 15 minutes. The wound should be scrubbed with an EZ scrub (prepackaged hexachlorophene scrub brush), using the bristle side vigorously. For eye exposure or mucous membrane exposure, irrigate with sterile saline or running water for at least 15 minutes.
4. Patient should be carrying a culture swab from the wound taken after cleansing. If this has not been done, check to be sure the wound has been cleansed and then proceed to swab the wound as deeply as you can, using one of the viral culture swabs. Place the swab in the vial containing the viral transport media, break off the end of the swab shaft and tightly seal the screw cap. Place the specimen in a biohazard transport bag and seal. All swabs should be marked regarding source and site.
5. Order laboratory Tests: Patient should be sent to lab with request marked with Dr. Risdahl’s provider number (571) ON a green lab request form under "other" write:
1. Acute serology for herpes virus simiae.
2. Wound culture (list site) for herpes virus simiae (see #4 above)
3. Dr. Risdahl or her designee will follow up on test results.
6. Make sure patient has current tetanus vaccine.
7. Patient must be seen and assessed by physician in Urgent Care before discharge.
8. If wound has any potential to be exposed to herpes virus simiae, even if remote or minor, the patient should be started on Valacyclovir 1 gram po tid for 14 days (500 mg tabs- 2 tabs po tid #84)(see BHS Detailed Health Care Provider Protocol).
9. Schedule follow-up visit with Dr. Risdahl or designee one week after exposure.
10. Instruct patient to return immediately if pain, numbness, paralysis, vesicular lesion, or other problems at the site of the wound or anywhere else.

Contact Boynton Health Service Occupational Health Director, Jeanne Ayers, (612-626-5422) or nursing supervisor to report that care was initiated for exposure. Resource persons: Dr. Risdahl, BHS, 624-1134; Dr. Gillett or Suzanne Ford, RAR: 624-9100.

Other Viral Infections

Nonhuman primates can develop measles, usually following exposure to infected humans.  Workers should be vaccinated against measles.  Workers with measles should not work with nonhuman primates until they have recovered.  Clinical signs in the animals are similar to those in humans, including a red rash on the face and hands.  Transmission is usually by direct contact.

Influenza virus can be transmitted between humans and nonhuman primates.  Signs of disease for both humans and animals include fever and upper respiratory signs such as coughing, sneezing and nasoocular secretions.  The disease is potentially fatal in immunocompromised individuals.  Transmission is by aerosol.  Prevention is achieved through the use of protective clothing and respiratory protection.

Several pox viruses, including monkeypox and Yaba virus can cause painful nodular lesions in the skin of humans and nonhuman primates.  Transmission is by direct contact, although infected tissues could present a risk to laboratory workers.  Prevention of disease is through use of protective clothing.

Nonhuman primates may be carriers of filoviruses such as Ebola.  These viruses cause an acute hemorrhagic fever in humans and nonhuman primates that is often fatal.  Flood and body fluids are potential sources of the virus.  Use of protective clothing and eyewear is preventative.  Animals are screened upon entry into the country for filoviruses.

Gastrointestinal disease

Bacterial agents such as Salmonella, Shigella, and intestinal parasites such as Giardia, Entamoeba histolyticaand Balantidium coli can be carried by many species of nonhuman primates.  Feces are the primary source of infections.  Gloves, a laboratory coat and a respiratory mask should be worn when handling fecal samples or sanitizing caging.  Symptoms of these diseases include diarrhea with or without blood, vomiting, and fever in both humans and nonhuman primates.  Medical attention should be sought immediately.

Bacterial pneumonia

Streptococcus pneumonia can cause an acute bacterial pneumonia in humans and nonhuman primates.  Infected animals and lung or sputum samples can present a risk to workers.  Sudden onset of fever, malaise and coughing are symptoms of bacterial pneumonia.  Medical attention should be sought immediately.

Tuberculosis

Mycobacterium tuberculosis causes a rapidly fatal pneumonia in most Old World primate species, and chronic pneumonia in humans.  Typically, infected humans present a much greater risk to the animals than animals do to humans.  It would be unusual for the disease to be transmitted to humans, unless the animal is undergoing surgery or pathologic examination.  Infected tissue samples can also present a risk to laboratory workers.  Prevention of disease includes routine use of respiratory protection and protective clothing when working with tissues or when coming into close proximity to animals.  Animals and human handlers are screened every 6 months for disease.  Animals are also quarantined and screened on entry into the facility.

Guidelines for Handling of Nonhuman Primate Clinical Samples

Training

All personnel in contact with clinical samples must be trained in the nature of the hazards presented by nonhuman primate samples, and in the methods for preventing exposure.  This training is available through RAR (call 624-9100).  Bloodborne pathogen training is also available through the Department of Environmental Health and Safety (call 626-2330).  The procedures presented in this training are identical to those presented by RAR, however, the risks are pertinent to human samples.  Refer to the above information on risks from nonhuman primate samples.

Personal Protective Equipment and Clothing

• Protective clothing should be worn when handling clinical samples. 
• Disposable gloves and long-sleeved protective clothing should be worn at all times
• If there is the potential for splashing (e.g. opening sample containers, pipetting, vortexing) eye and respiratory protection should be used.  This should include a respiratory mask with a moisture barrier and a splash guard, safety glasses with side panels, or or a face shield.
• Protective clothing should be replaced if it is contaminated.
• Protective clothing should be removed on leaving the work area and placed in a biohazard disposal container or laundry.
• Wash hands after removing gloves.

Procedures

• Follow proper sharps handling procedures. 
• Don’t recap needles, if possible.  If it is necessary to recap, use a device or a one-handed technique.
• Use a piece of cardboard or other device to pick up broken glass or loose sharps.  This should be discarded or decontaminated following use.
• Dispose of sharps in a puncture-proof container labeled "Biohazard".
• If there is a spill, decontaminate the spilled material with 10% bleach or a similar disinfectant.
• Use a device, not your mouth to pipette samples.
• Samples should be kept in unbreakable, leak-proof containers.  Place the primary container in a secondary container when transporting samples or when the primary container has become contaminated on the outside.
• Decontaminate work surfaces after use using an appropriate disinfectant, such as 1% bleach.
• Areas where samples are stored should be labeled with a red or orange biohazard sign.
• If samples are to be mailed or transferred to another location, the container should labeled as a biohazard with a red or orange label.  Any special shipping procedures required by law or by the carrier for biohazard samples should be followed.
• Further details on laboratory procedures are found in the CDC publication Biosafety in Microbiological and Biomedical Laboratories.

Exposure to body fluids or tissues

Post-exposure procedures should be followed if there is a needle stick, or exposure of body fluids or fresh tissues to broken skin or a mucous membrane.  Refer to the attached page or, the "Nonhuman Primate Bite Kit" found in nonhuman primate housing areas.