Veterinary Medicine during a Time of Restriction of Elective Services and Social Distancing Dr. Scott Weese, DVM, DVSc, DACVIM University of Guelph

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During the current COVID-19 pandemic, strong public measures are being enacted to reduce the spread of this disease. These have profound impacts on day-to-day activities and require a balance between providing veterinary care and being socially responsible from a COVID-19 standpoint. There are few clear answers and guidance may change. The information below is meant to be a guide, and there may be differences in jurisdictions and practices that necessitate different approaches . Veterinary clinics must be aware of specific restrictions in their area. There may also be regional differences in regulatory guidance or regulations for approaches such as telemedicine. The goal of restricting services is to ensure veterinarians will be allowed to continue, and have the required physical and human resources, to provide needed veterinary care for the duration of this unprecedented event.

Index                                                                                Elective vs. essential procedures                                 Owner risk assessment                                                 Social distancing                                                            High-risk households                                                     Staff monitoring                                                            Staff behaviour

ESSENTIAL VS. NON-ESSENTIAL PROCEDURES As restrictions in elective or non-essential services are put in place, either voluntarily or through government or regulatory body mandates, careful consideration of what is considered essential is needed. There is no standard list of elective/essential procedures. Essential procedures include those required to alleviate animal pain and suffering, to prevent imminent threat of death of the animal, and matters pertaining to public health (e.g. vaccination against rabies). Other considerations may be involved, including supply availability, the ability of the clinic to practice appropriate social distancing, and factors related to management of specific cases either in the clinic or at home. Both animal welfare and owner welfare (i.e. human animal bond aspects) are important parts of these decisions, particularly as companion animals may be critical support mechanisms to many people during these challenging times. Recommendations may change based on our growing understanding of this disease, changes in messaging from governments and regulators, and as this pandemic evolves. Veterinarians and owners must understand this is a fluid situation and the goal cannot be maintaining “business as usual”, but rather providing the optimal outcomes for animals, owners and veterinary facilities, while doing our part to support social distancing efforts . Any consultations that do not absolutely require physical contact with the animal should be done via telemedicine if at all possible. The table below provides some general guidance for regular clinic activities, but is not absolute. Veterinarians must use their judgement in determining whether certain services or procedures may be deemed essential for specific clients or patients based on their circumstances.

Service Advice

Wellness visits Postpone.

Food sales Continue but maintain social distancing (see below), arrange delivery or use eCommerce.

Medication refills Continue but maintain social distancing (see below), arrange drop-off or use eCommerce.

Rabies vaccination Routine vaccination (including previously unvaccinated animals) can be reasonably postponed if the owner is able to manage the animal in such a way as to minimize the risk of exposure until the animal can be vaccinated.* Veterinarians must use their judgement in determining if the animal cannot be appropriately managed and is at increased risk of rabies exposure, and therefore routine rabies vaccination is essential. Rabies vaccination after a potential rabies exposure incident must continue to be given within 7 days if the offending animal (e.g. bat, wildlife) is not available for testing.

Other vaccinations Administer boosters of vaccine series that have started if deemed necessary based on the animal’s condition and circumstances (e.g. risk of exposure). Postpone other vaccinations if the risk of exposure can be managed otherwise in the interim.

Heartworm prophylaxis If pets have been on prophylaxis in previous years, dispensing without a heartworm test is reasonable. Maintain social distancing (see below), arrange delivery or use eCommerce. If there are concerns about owner compliance or if prophylaxis history is unclear (or absent), risks should be discussed with the owner, but preventives can be dispensed without testing with owner consent. Visits to clinics for heartworm testing should be postponed.

Flea/tick preventives Dispense to established clients, maintaining social distancing or arranging for drop-off or delivery. Establish VCPR via telemedicine for new clients prior to dispensing.

Life threatening conditions With cases from low-risk households, manage using social distancing (see below). With cases from high-risk households, determine the required PPE and whether the case can be managed at your clinic (see below for description of low vs high risk households).

Management of painful conditions Manage by telemedicine when possible. If examination is needed and the pet is from a low-risk household, admit for examination, maintaining social distancing.

Management of chronic conditions Maintain by telemedicine when possible. Schedule appointment if examination is needed and a delay would lead to a reasonably likelihood of a negative patient outcome.

Surgical procedures for painful disorders If the patient can be temporarily maintained on analgesics with a low risk of negative consequences, delay the surgery. If not, proceed with the surgery if household is low-risk. If household is high-risk, determine the required PPE and whether the case can be managed at your clinic, or if possible isolate the animal from any high-risk individuals for 2-3 days to minimize the risk of contamination of the haircoat and then proceed with the surgery.

Other non-urgent surgical procedures Postpone.

Routine hematologic monitoring  This should be postponed unless it is felt that a delay would substantially increase the risk of complications.

Routine fecal/urine testing Since these samples can be collected by the owner and dropped off without social interaction, testing can be performed. Packages should be handled by personnel wearing gloves and a lab coat, and handled as potentially infectious. Containers should be wiped with a disinfectant. If containers are retained (e.g. for subsequent testing) they should be placed in a new sealable bag.

Euthanasia Humane euthanasias should proceed, limiting social interactions as much as is reasonable while respecting the needs of the human-animal bond. Consider necessary PPE for staff if the animal is from a high-risk household.

House calls Approach as per the individual procedures listed above, recognizing the greater risk to veterinary personnel entering a household and the need for owner risk assessment (see below). Maintain social distancing within the household as much as possible.

Chemotherapy Continue ongoing treatment while maintaining social distancing. If possible, consider alternate regimes that may spare PPE supplies (e.g. oral) if there is minimal risk of a negative impact on the animal’s condition.  Consider the clinical implications of delays when deciding whether to start new chemotherapy treatment regimens

Boarding, day care, grooming, and other ancillary services  Discontinue.

* In Ontario, this is equivalent to how an animal must be managed if it is given medical certificate of exemption from rabies immunization (e.g. must be leashed at all times when in public, must be directly supervised at all times when outside). Local animal health authorities may need to be consulted to discuss the ramifications of letting rabies vaccination lapse.

OWNER RISK ASSESSMENT A risk assessment should be performed for any potential appointment or other owner/clinic contact. This is designed to identify individuals and/or animals that are at increased risk of COVID-19 exposure or shedding before they enter the clinic. This allows for time to determine what measures to use for the protection of clinic personnel and the broader population. The risk assessment involves identification of factors that indicate a higher than average risk that the owner is infected, and correspondingly the potential that the animal has been exposed or contaminated. The usefulness of this will be impacted by the epidemiology of COVID-19 in the specific area. As community transmission increases, screening is less effective, since more infections occur without identifiable risk factors. However, screening can still help identify at least a subset of higher risk situations and identify households with potentially active disease. If respiratory disease is reported by any household member or close contacts of the animal, they should be directed to complete the Ontario self-assessment tool for COVID-19 ( https://covid-19.ontario.ca/self-assessment/#q0) or your provincial equivalent.

SOCIAL DISTANCING Social distancing aims to reduce the number of human-human contacts and to reduce the closeness of those contacts. Transmission of SARS-CoV-2 is mainly through aerosols, direct contact and potential contact with contaminated surfaces. Avoiding direct and indirect (e.g. passing items) contact and maintaining 2 metre (6 feet) separation should greatly reduce the transmission risk. Various measures can be implemented in veterinary clinics to facilitate social distancing. Specific application can vary based on the nature of the clinic, but general approaches that should be considered are outlined below. Admission & discharge : The animal should be transferred with little to no human-to-human contact, regardless of the status of the person bringing the animal. This can consist of arms-length handing off of a leash or carrier outside of the clinic, dropping a carrier inside the main clinic door with no clinic personnel present, or other clinic-specific approaches. The same approaches can be used for patient discharges. Telemedicine : Telemedicine should be considered for consultations, even those that involve a new clinical concern. While not all cases can be managed by telemedicine, telemedicine provides the ability to provide good veterinary care to a reasonable subset of the patient population. Telemedicine can be complemented with drug/food delivery and owner drop-off of some specimens (e.g. urine, feces). Cashless payment : Credit card information can be obtained over the phone and this is the preferred approach. Cards can be tapped for smaller amounts, but this requires the owner to be in the vicinity of personnel. Owners should be asked to avoid touching the machine. eTransfer may be an option in some situations. These should be encouraged as much as possible, ensuring there is still an ability for the small subset of the population that cannot or does not use credit or debit for payment to obtain veterinary care. Verbal consent : Signatures should be avoided because of the need to pass paper and pens. Documentation of verbal consent in the medical record is an acceptable approach. If there are concerns about a specific situation, documentation of verbal consent could be supplemented with recording of verbal consent (with client permission), or having a second staff member witness/confirm the consent by phone and document that accordingly in the record. Staff cohorting : When possible, staff groups should be kept together to minimize the number of different human contacts and to minimize the implications of any one staff member being infected. Arranging for delivery of food and medications : To reduce the number of individuals coming to the clinic, when possible, delivery or shipment of items to the owner’s residence should be used. This can include commercial eCommerce platforms for direct shipment, or delivery by clinic personnel. Care should be taken when using local commercial services that involve meeting with drivers. If those are needed, careful social distancing must be used for all interaction with drivers at pick up. Preventing walk-ins : People should be kept out of clinics apart from pre-scheduled appointments or pick-ups, where risk has been assessed and where measures are in place to minimize contact. Signage can be useful, but is often missed or ignored. Locking doors, with a contact number to call, is more effective.

LOW- VS HIGH-RISK HOUSEHOLDS

Highest risk households consist of those with: People with confirmed or suspected COVID-19 infections People who are self-isolating and developed respiratory tract disease

High-risk households are those that have people with known or suspected COVID-19 infections, as well as those in which a person has been self-isolating and subsequently developed signs of respiratory disease, even if COVID-19 testing has not been performed. Households with one or more individuals with respiratory disease indicated to self-isolate as per the Ontario self-assessment checklist ( https://covid-19.ontario.ca/self-assessment/#q0 ), or your provincial equivalent, are also included. If admission of an animal from a high-risk household is needed, clinics should ensure they have the required equipment and training to do so safely. If they cannot safely manage the patient and appropriately protect staff from potential exposure, the animal should be diverted to a facility that can. If the animal is to be admitted, it should be transferred with no human contact, regardless of the status of the person bringing the animal (see admission and discharge of animals under social distancing above). History and consent should be obtained verbally by phone or computer. Nothing beyond the animal and its leash and collar, or crate/carrier, should be taken into the clinic. Leashes should be switched as soon as practical and safe. Owner leashes, if still on the animal at the time of clinic entry, should be bagged and set aside for future return. Cages should be sprayed with disinfectant. Any items in cages (e.g. paper, towels) should be discarded as biohazardous waste or bagged for future return. Personnel handling the animal at admission should wear a gown and gloves, at a minimum. If there is potential that the patient will contact the person’s lower legs (e.g. dog on a leash), it should be ensured that the gown (or alternative outerwear) covers all lower leg contact sites. Foot covers should be considered when bringing in a dog on a leash, because of the potential for the dog to nose or lick. Surgical masks can be considered for routine handling to reduce inadvertent hand-to-mouth/nose contact. Personnel handling the animal should be kept to a minimum. Procedures should also be kept to the minimum required to properly manage emergent care. For non-emergent care where the patient must be admitted, handling should be minimized, particularly during the first 1-2 days, to reduce the risk of fomite transmission. All personnel involved in patient handling or procedures should wear a gown and gloves, at a minimum. Those not involved with the case should be kept out of the room. Mask and eye protection or face shield should be worn if there will be close contact during restraint and procedures. For work that will potentially involve contact with aerosols (e.g. working around a dog’s face, intubation), an N95 mask should be used in place of a surgical mask. If an N95 mask is not available, a surgical mask and face shield is likely an acceptable alternative if care is taken to ensure the user faces the patient at all times during aerosol generation (to avoid exposure through the sides). If the patient’s condition and temperament permit, decontamination of the haircoat can be attempted. This can be done through routine bathing (e.g. 2-4% chlorhexidine shampoo), wiping with disinfectant wipes, application of half strength accelerated hydrogen peroxide (Prevail TM , Rescue TM ), or application of topical biocide rinses or mousses (e.g. chlorhexidine). Particular care should be taken around ferrets, as they may be the most susceptible domestic animal species to COVID-19. PPE recommendations outlined above would still apply, with use of N95 masks if there is potential for any aerosol generation.

STAFF MONITORING Staff should be diligent in social distancing and monitoring their health. Any staff member that develops a fever or signs of respiratory disease should complete the Ontario self-assessment checklist ( https://covid-19.ontario.ca/self-assessment/#q0 ), or your provincial equivalent, and act as per the provided recommendations.

STAFF BEHAVIOUR Social distancing requires broad and consistent efforts. Clinics should have open discussions with staff members about the need for them to use excellent social distancing practices outside of work. Staff pose a significant risk to clinical personnel because of difficulties social distancing while working within a clinic. Therefore, staff must be responsible outside of work hours to reduce the risk to coworkers and the clinic as a whole. Exercising social distancing within the clinic as much as possible, as well as emphasis on diligent hand hygiene and respiratory etiquette at all times, is also crucial.

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Canadian Association for Laboratory Animal Medicine L’association canadienne de la médecine des animaux de laboratoire CALAM/ACMAL National Teleconference: COVID-19 - March 25, 2020

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