Master of Public Health / Department of Diagnostic Medicine/Pathobiology / Douglas Powell / Outbreaks of human illness have been linked to visiting settings with animal contact throughout developed countries. These outbreaks demonstrate that although contact with animals in public settings can provide educational and entertainment opportunities, the potential to spread disease exists if risk-reduction tools are not implemented, proper hygiene measures aren’t practiced, and precautions are not taken and reinforced. This thesis is divided into two parts. Part one is an observational study of hand hygiene tool availability and recommendations; frequency of risky behavior; and, handwashing attempts by visitors in Kansas and Missouri, U.S., petting zoos. Part two delineates best practices for organizing events where human-animal interactions are encouraged, in hopes it will lower the risk of zoonotic disease transmission. Handwashing signs and hand hygiene stations were available at the exit of animal-contact areas in 10/13 and 8/13 petting zoos respectively. Risky behaviors were observed being performed at all petting zoos by at least one visitor. Frequently observed behaviors were: children (10/13 petting zoos) and adults (9/13 petting zoos) touching hands to face within animal-contact areas; animals licking children’s and adults’ hands (7/13 and 4/13 petting zoos, respectively); and children and adults drinking within animal-contact areas (5/13 petting zoos each). Of 574 visitors observed for hand hygiene when exiting animal-contact areas, 37% (n=214) of individuals attempted some type of hand hygiene, with male adults, female adults, and children attempting at similar rates (32%, 40%, and 37% respectively). Visitors performed hand hygiene more often when a staff member was present within or at the exit to the animal-contact area (136/231, 59%) than when no staff member was present (78/343, 23%; P < 0.001, OR = 4.863, 95% CI = 3.380–6.998), and in petting zoos where animal contact occurred over a fence (188/460, 40.9%) as opposed to visitors entering an animals’ yard for contact (26/114, 22.8%; P < 0.001, OR = 2.339, 95% CI = 1.454–3.763). Inconsistencies existed in tool availability, signage, and supervision of animal- contact. Risk communication was poor, with few petting zoos outlining risks associated with animal-contact, or providing recommendations for precautions to be taken to reduce these risks. Recommendations made in the second part of this thesis were based on these observations, recent publications, and the suggestions of many health agencies. It focuses on what event planners can do to design and plan a safer event, and what staff working at the event should be aware of in order to inform visitors and lower the risk of zoonotic disease transmission. Part two discusses two primary tools to reduce risk of zoonotic disease transmission: sanitation and awareness of risk behaviors. Keeping facilities, animals, and visitors clean, and informing visitors of risky behaviors to avoid, while reinforcing positive messages within the animal- contact area, can lower the risk of zoonotic infection. Included with the second part, is a checklist (see appendix A) designed for visitors to assess whether an event that encourages human-animal interaction poses a high or low risk. By identifying possible risk factors, teachers and parents will be able to make an informed decision about the safety of the human-animal encounter.

This thesis is an investigation of the use of various infection control practices, including hand hygiene, in companion animal veterinary clinics and a public petting zoo. Video observation of petting zoo visitors found overall hand hygiene compliance was 58% (340/583). Improved signage with offering hand sanitizer (odds ratio (OR) 3.38, p<0.001) and verbal hand hygiene reminders (OR 1.73, p=0.037) had a significant positive association with compliance. Video observation of preoperative preparation practices in ten veterinary clinics found contact times with preparatory solutions were often shorter than recommended: 10-462s for patients and 7-529s for surgeons using soap and water. Practices that did not conform to guidelines available in major companion animal surgical textbooks were commonly observed. A survey of veterinary staff found that over 80% of respondents ranked hand hygiene as of high importance in all clinical situations queried. The most frequently reported reason for not performing hand hygiene was forgetting to do so (40%, 141/353). Video observation of various infection control practices in 47 veterinary clinics found that poor sharps handling practices were common, yet only one needlestick injury was observed. Exam tables were cleaned following 76% (2015/2646) of appointments, and contact time with spray used to do so ranged from 0-4611s (mean 39s, median 9s). Appropriate personal protective clothing was worn for 72% (3518/4903) of staff-animal contacts. Video observation of hand hygiene practices in 38 veterinary clinics found overall hand hygiene compliance was 14% (1473/10894). Soap and water was used for 87% (1182/1353) of observed hand hygiene attempts with a mean contact time of 4s (median 2s, range 1-49s). A hand hygiene poster campaign had no significant effect on compliance. There is clearly room for improvement with regard to many frequently used infection control measures in veterinary clinics in Ontario. Use of active interventions to improve practices such as hand hygiene should be investigated in clinics, as such measures have been effective in other settings. The video monitoring system used in this research may be a useful tool for conducting these and similar studies in the future. A better infection control culture needs to be established in veterinary medicine. Accompanying data files are located at: http://hdl.handle.net/10864/10445 / Canadian Institutes of Health Research (CIHR), Ontario Veterinary College Pet Trust, Canada Foundation for Innovation

An increase in outbreaks caused by zoonotic agents has brought about intensified efforts to address the transmission of infectious organisms in animal settings. In October 2002, the CDC released recommendations for the use of waterless hand sanitizer (WHS) in human healthcare settings. The question arises whether WHS may be as effective in veterinary and animal agricultural settings given some of the dissimilarities in conditions. To address this question, three studies were conducted. The first was a retrospective analysis of a Samonella agona outbreak which occurred in 2001 at the Large Animal Teaching Hospital of the Virginia-Maryland Regional College of Veterinary Medicine (VMRCVM). The second evaluated the pattern of use and efficacy of hand hygiene products in the VMRCVM Large Animal Hospital. The third study assessed the efficacy of WHS among visitors to a children's petting zoo at the 2002 Virginia State Fair. Regarding the Salmonella outbreak, it is thought that a calf from the university owned dairy herd was the index case. A total of 16 equine patients acquired S. agona while hospitalized. The nosocomial disease incidence risk for in-house patients was estimated to be 33% (16/49). The LAH was closed for 7 months for cleaning, disinfection and renovation. The total cost of the outbreak was estimated to be at least $755,000. Waterless hand sanitizer proved useful in the veterinary hospital setting. When measured immediately after use, WHS reduced bacterial loads on the hands of 20 LAH personnel (P < 0.001). Before WHS use, HBC ranged from less than to 20 to 48,800 CFU/ml with a geometric mean of 6,926 CFU/ml. Counts after WHS use ranged from less than 20 to 23,400 with a geometric mean of 1,152 CFU/ml. Differences in before and after ranged from -4,000 to 48,200 CFU/ml with a median of 9,700 CFU/ml. The logarithmic reduction in bacterial load before and after WHS use was 0.78 (79.7%). In the petting zoo study, bacterial counts on the fingers of the children sampled before use of WHS ranged from 40 to 75,200 CFU/ml with a geometric mean of 8,653 CFU/ml. After WHS use, bacterial growth ranged from 19 to 58,400 CFU/ml with a geometric mean of 1,727 CFU/ml. Differences in before and after ranged from -35,600 to 59,400 CFU/ml with a median of 8,190 CFU/ml. The logarithmic reduction in bacterial load before and after WHS use was 0.70 (82.2%; P< 0.001). These data suggest that WHS may be of benefit in veterinary medicine and animal agriculture as a means to reduce nosocomial and zoonotic infections. / Master of Science