Herpes B Virus Review & Exposure Training

1. Herpes B Virus Review & Exposure Training East Carolina University Department of Comparative Medicine 2013

2. B Virus Information B virus, or Macacine herpesvirus 1(formerly Cercopithecine herpesvirus 1 [CHV-1]), an alphaherpesvirus is an infectious agent that is commonly found among macaques: rhesus, pig-tailed, and cynomolgus monkeys.

3. B Virus Information • B Virus naturally occurs in macaque monkeys. • Acts relatively benign in its natural host- In the macaque, B virus causes mild symptoms that are similar to that of herpes simplex virus 1 (HSV types 1 or 2) in humans. • These symptoms can include oral or genital lesions, but virus can be shed in the absence of lesions as well. • After initial infection, the B virus can remain latent in the dorsal root of spinal nerves subserving the region of exposure or cranial ganglia of both natural and foreign hosts. http://www.cdc.gov/herpesbvirus/index.html

4. Gross lesions of Herpes B that may be present

5. B Virus continued • B virus is transmitted from a host when virus is shed from herpetic lesions or the affected mucosal sites. • How often or how long the host sheds is not yet fully understood. • This virus can cause rapidly ascending encephalomyelitis in humans • A fatality rate of approximately 80% if spread to humans (through bites, scratches, splashes, or needle-stick injuries). • Incubation periods may be as short as 2 days, but more commonly they are 2 to 5 weeks

6. First Aid and Treatment • http://www.cdc.gov/herpesbvirus/firstaid-treatment.html • First aid should begin immediately: • Cleanse the exposed area by thoroughly washing and scrubbing the area or wound with soap, concentrated solution of detergent, povidone-iodine, or chlorhexidine and water, and then • Irrigate the washed area with running water for 15-20 minutes.

7. Monkey Incident Protocol

8. Monkey Incident Protocol

9. Monkey Incident Protocol • Exposures/Incidents are defined as bites or scratches from macaques (does not have to break the skin); ocular and/or mucous membrane exposure from splashing water, body secretions, or urine during animal room or cage sanitation; needle sticks; and/or injury sustained by handling cages or equipment potentially contaminated with nonhuman primate secretions. • Following first aid treatment, employees who have been exposed will be referred to the Office of Prospective Health for follow-up care, including detailing signs/symptoms to be aware of that might indicate an infection. • If you are not sure that an incident qualifies as an exposure, please proceed with the first aid protocol and then contact a DCM veterinarian after you have completed the first aid procedures.

10. Monkey Incident Protocol TAKE HOME MESSAGE- WASH/ FLUSH EXPOSURE SITE 15 min for best outcome

11. Monkey Incident Protocol Procedures-Person (Prospective Health or Emergency Room Physicians) • Health care provider will evaluate lesion and re-cleanse if high-risk exposure (deep puncture or mucosal exposure). Cleanse by washing the wound with povidone-iodine, chlorhexidine, or detergent soap for 15 minutes for a skin wound, or irrigate eyes and mucous membranes for 15 minutes with sterile saline or water. • Draw a red top tube and label it with the patient’s name and the date. • Open one of the prepackaged viral collection and submission packets in the “B virus culture/serology kit”. Remove a sterile swab (cotton tipped applicator) from the kit. Swab the wound with the cotton tip. Remove the cap from the vial of viral transport medium being careful not to touch the neck of the vial or the inside of the cap. Carefully, without touching the swab tip to the top of the vial, place the swab in the vial of transport media, break off the shaft, and securely replace the cap. • Complete the information on the vial label including patient name, date, swab site, and animal ID if known. (Example: John Doe; October 31, 2010; left forearm; ABC 21), then place the vial back in its package • Prospective Health : return all samples to employee for processing and shipping by DCM diagnostic lab to the NIH B virus reference laboratory for testing. • Emergency Room Physicians (see enclosed laminated cards): Instruct PCMH lab to collect blood in a red top tube, spin and remove serum, and store serum in refrigerator overnight; viral culture samples must also be refrigerated. Use a miscellaneous lab slip for these procedures - DO NOT USE a Clinical Lab slip or send the samples out. Samples will be picked up by DCM staff the next business day. • After treatment by the physician, the exposed employee must fill out an “Accident Report” form in LSB-208. The information on this form will identify the physician who administered care as well as details of the treatment provided.

12. Monkey Incident Protocol • PROCEDURES-MONKEY (DCM Veterinarian) • Examine the animal(s) for skin, oral, or genital lesions indicative of infection, preferably within 8 hours and no later than 24 hours post-exposure. • Obtain swabs (≥ 4) for viral culture from the NHP’s mouth, both conjunctiva, urogenital area, and from any lesion noted at the time of physical exam. Swabs and vials for viral culture are available in the DCM diagnostic lab. Culture media must be kept cold after collection. Store transport media containing swabs in refrigerator if not shipping out that day (viral swabs may be held refrigerated up to 1 week). • Draw blood from the animal during initial physical exam and again at 2-3 weeks after the human exposure; submit to DCM diagnostic lab for processing. Try to coordinate monkey blood collection with human sample collection. Serum may be refrigerated for up to 1 week. • From dead macaques (recently euthanized or undergoing terminal procedure) obtain 3X5 mm nerve tissue samples (preferably right and left trigeminal ganglia and sacral dorsal root ganglia) from the animal for viral PCR and store in viral culture media; samples may be refrigerated for up to 1 week.

13. Monkey Incident Protocol • PROCEDURES-SAMPLES (DCM Diagnostic Lab) • Prepare and submit samples to B virus reference lab as instructed in the “Monkey exposure” book (during work hours, the samples are delivered to the lab by the employee and the veterinarian.) • If incident occurred after hours, pick up sample in the PCMH lab. • Enter information into monkey log located in LSB236 on the shelf by the door. • Samples required from employee are a serum sample and a swab from the wound or injury site. • Samples required from the monkey are a serum sample and multiple swabs. • Samples are to be shipped overnight on dry ice. Please call Dr. Hilliard’s NIH B virus laboratory before shipment. If samples are submitted on Friday, mark the package clearly to specify Saturday delivery.

14. Monkey Incident Protocol PROCEDURES- FOLLOW UP • Employee-14-21 days following the incident, the employee must report back to Prospective Health for additional follow-up viral screening. At this time, a second blood sample will be drawn for viral titer evaluation. Prospective Health will discuss all results with the employee, as well as possible symptoms of an infection. Employee brings sample to DCM lab. • Macaque -A veterinarian or member of the veterinary staff will obtain the serum sample from the monkey(s) involved (if known). DCM lab submits both human and monkey samples to B virus lab. • Results- Human results are sent directly by the testing lab to the Director of Prospective Health. NHP results are received by the designated DCM veterinarian, with a copy filed in each involved primate’s medical record. A copy is submitted to DCM accounting for billing. The originals are filed in the monkey incident log located in the DCM diagnostic lab. All results are communicated to the Director of Prospective Health.

15. Monkey Incident Protocol - KIT KIT CONTENTS • “ Monkey incident kit” • Copy of Monkey Incident Protocol #5001 • Sterile povidone iodine scrub brushes • timer • Sterile 4x4 gauze • Band aids in assorted sizes • Cloth tape • B virus culture/serology kit • Article • “B virus Culture/Serology kit” • Two serum collection tubes • 3 viral transport media and cotton swabs • Laminated instructions, three cards

16. KIT Cards Take them with you and Give to appropriate personnel !! • Emergency Physician Herpes B Exposure Instructions • Wash wound 15 minutes with chlorhexidine or povidone iodine • Treat patient/wound as appropriate: avoid sutures unless cosmetically necessary. • Antibiotics may be appropriate. • Verify tetanus status of patient. • Swab wound with cotton tipped applicator provided by patient and place into viral culture media. • Label viral culture tube with name, date, injury site, and animal number (if applicable). • Draw 5-7 ml blood in red serum separator/speckled tube. • Label the serum separator tube with patient name and date. • Send to the PCMH lab the viral culture, the serum separator tube, and patient and laminated card: • “lab instructions for samples for Herpes B exposure” • PCMH Lab instructions for samples from Herpes B exposure • Blood products may carry Herpes B virus, which is fatal in humans. • Place viral culture vial in a labeled (DCM ONLY) container in refrigerator. • Spin red top and store labeled sera (DCM ONLY) in refrigerator. • DCM staff will collect samples on the next business day for shipment. • Nonhuman primate exposure procedures • Splash in eyes, nose, or mouth requires 15 minutes flush at eyewash station. • Bite, scratch, needle stick, cut requires 15 minute scrub with bite kit contents. • Go to Prospective Health Office with bite kit. • Inform your supervisor and submit an injury report. • After hours, go to PCMH Emergency Room after 15 minute scrub or flush. • If injury is severe, go directly to PCMH Emergency Room. • Take entire kit with you to Emergency Room.

17. NHP PPE Requirements • Shoe covers • Hair cover • Gloves • Protective Eyewear (splash proof when appropriate) • Mask • Tyvex Suit

18. NHP PPE

19. Resources and Publications For more information regarding B virus and B virus infection see the following online resources: • Cohen JI, Davenport DS, Stewart JA, Deitchman S, Hilliard JK, Chapman LE; B virus Working Group. Recommendations for prevention of and therapy for exposure to B virus (Cercopithecineherpesvirus 1).Clin Infect Dis 2002;35:1191-203. Epub 2002 Oct 17. • Centers for Disease Control and Prevention and National Institutes of Health. Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th Edition. Washington, DC: US Government Printing Office. 2007. • Centers for Disease Control and Prevention and National Institutes of Health. Biosafety in Microbiological and Biomedical Laboratories (BMBL) 5th Edition. Section VIII—Agent Summary Statements and Section VIII-E: Viral Agents. Washington, DC: US Government Printing Office. 2007. • CDC National Institute for Occupational Safety and Health (NIOSH) Hazard ID 5: Cercopithecineherpesvirus 1 (B virus) Infection Resulting from Ocular Exposure. • National Association of State Public Health Veterinarians - Compendium of Measures to Prevent Disease Associated with Animals in Public Settings, 2009MMWR Recomm Rep 2009; 58(RR05);1-15. • Recommendations for precautions to be taken with research animals and pets can be found at • http://www.ahc.umn.edu/rar • http://www.cdc.gov/healthypets • http://www.cdc.gov/hiv/pubs/brochure/oi_pets.htm • U.S. Public Health Service, Department of Health and Human Services’ Code of Federal Regulations—42CFR73.3