Animals in Healthcare Facilities: Recommendations to Minimize Potential Risks

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Animals in Healthcare Facilities: Recommendations to Minimize Potential Risks - Volume 36 Issue 5 - Rekha Murthy, Gonzalo Bearman, Sherrill Brown, Kristina Bryant, Raymond Chinn, Angela Hewlett, B. Glenn George, Ellie J.C. Goldstein, Galit Holzmann-Pazgal, Mark E. Rupp, Timothy Wiemken, J. Scott Weese, David J. Weber

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Animals in Healthcare Facilities: Recommendations to Minimize Potential
Risks
Rekha Murthy, Gonzalo Bearman, Sherrill Brown, Kristina Bryant, Raymond Chinn, Angela Hewlett, B. Glenn George, Ellie
J.C. Goldstein, Galit Holzmann-Pazgal, Mark E. Rupp, Timothy Wiemken, J. Scott Weese and David J. Weber
Infection Control & Hospital Epidemiology / FirstView Article / March 2015, pp 1 - 22
DOI: 10.1017/ice.2015.15, Published online: 02 March 2015
Link to this article: http://journals.cambridge.org/abstract_S0899823X1500015X
How to cite this article:
Rekha Murthy, Gonzalo Bearman, Sherrill Brown, Kristina Bryant, Raymond Chinn, Angela Hewlett, B. Glenn George, Ellie
J.C. Goldstein, Galit Holzmann-Pazgal, Mark E. Rupp, Timothy Wiemken, J. Scott Weese and David J. Weber Animals in
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shea expert guidance
Animals in Healthcare Facilities: Recommendations
to Minimize Potential Risks
Rekha Murthy, MD;
1
Gonzalo Bearman, MD, MPH;
2
Sherrill Brown, MD;
3
Kristina Bryant, MD;
4
Raymond Chinn, MD;
5
Angela Hewlett, MD, MS;
6
B. Glenn George, JD;
7
Ellie J.C. Goldstein, MD;
8
Galit Holzmann-Pazgal, MD;
9
Mark E. Rupp, MD;
10
Timothy Wiemken, PhD, CIC, MPH;
4
J. Scott Weese, DVM, DVSc, DACVIM;
11
David J. Weber, MD, MPH
12
purpose
Animals may be present in healthcare facilities for multiple
reasons. Although specific laws regarding the use of service
animals in public facilities were established in the United States
in 1990, the widespread presence of animals in hospitals,
including service animals to assist in patient therapy and
research, has resulted in the increased presence of animals in
acute care hospitals and ambulatory medical settings. The role
of animals in the transmission of zoonotic pathogens and
cross-transmission of human pathogens in these settings
remains poorly studied. Until more definitive information is
available, priority should be placed on patient and healthcare
provider safety, and the use of standard infection prevention
and control measures to prevent animal-to-human transmis-
sion in healthcare settings. This paper aims to provide general
guidance to the medical community regarding the manage-
ment of animals in healthcare (AHC). The manuscript has
four major goals:
1. Review and interpret the medical literature regarding risks
and evidence for animal-to-human transmission of patho-
gens in the healthcare setting, along with the potential
benefits of animal-assisted activities in healthcare.
2. Review hospital policies related to AHC, as submitted by
members of the SHEA Guidelines Committee.
3. Summarize a survey that assessed institutional AHC policies.
4. Offer specific guidance to minimize risks associated with
the presence of AHC settings.
Recommendations for the safe oversight and management of
AHC should comply with legal requirements and minimize the
risk of transmission of pathogens from animals to humans
when animals are permitted in the healthcare setting. Although
little published literature exists on this topic, we provide
guidance on the management of AHC in four categories:
animal-assisted activities, service animals, research animals,
and personal pet visitation. Institutions considering these
programs should have policies that include well-organized
communication and education directed at healthcare personnel
(HCP), patients, and visitors. Appropriately designed studies
are needed to better define the risks and benefits of allowing
animals in the healthcare setting for specificpurposes.
background
The Role of Animals in Healthcare Settings (AHC)
People come into contact with animals in a variety of settings
including households (pets), occupational exposure (veterinarians,
farmers, ranchers, and forestry workers), leisure pursuits
(hunting, camping, and fishing), petting zoos, and travel to rural
areas. Pet ownership is common in the United States. A national
poll of pet owners revealed that in 2013–2014, 68% of US
households included a pet with the number of households
owning specific animals as follows: dogs 56.7 million, cats
45.3 million, freshwater fish 14.3 million, birds 6.9 million,
small animals 6.9 million, reptiles 5.6 million, horses 2.8 million,
and saltwater fish 1.8.
1
Patients in healthcare facilities come into contact with ani-
mals for 2 main reasons: 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 or education, and personal pet visits to
their owners in the hospital (personal pet visitation). Risks to
patients from exposure to animals in the healthcare setting
may be associated with transmission of pathogens through
Affiliations: 1. Cedars-Sinai Medical Center, Los Angeles, California; 2. Virginia Commonwealth University, Richmond, Virginia; 3. Kaiser Permanente
Medical Center, Woodland Hills, California; 4. University of Louisville, Louisville, Kentucky; 5. Sharp Metropolitan Medical Campus, San Diego, California;
6. University of Nebraska Medical Center, Omaha, Nebraska; 7. UNC Health Care System and UNC School of Medicine, Chapel Hill, North Carolina;
8. David Geffen School of Medicine at UCLA, R.M. Alden Research Laboratory, Santa Monica, California; 9. University of Texas Medical School, Houston,
Texas; 10. University of Nebraska Medical Center, Omaha, Nebraska; 11. University of Guelph Centre for Public Health and Zoonoses, Guelph, Ontario,
Canada; 12. University of North Carolina, Chapel Hill, North Carolina.
© 2015 by The Society for Healthcare Epidemiology of America. All rights reserved. DOI: 10.1017/ice.2015.15
Received December 18, 2014; accepted December 21, 2014
infection control & hospital epidemiology

direct or indirect contact or, less likely, droplet/aerosol trans-
mission (Table 1); however, insufficient studies are available
to produce generalizable, evidence-based recommendations
(Table 2); therefore, wide variations exist in policies and
practice across healthcare institutions.
Risks of Animals in Healthcare
Few scientific studies have addressed the potential risks of animal-
to-human transmission of pathogens in the healthcare setting.
Furthermore, because animals have, in general, been excluded
from hospitals, experience gained by means of case reports and
outbreak investigations is minimal (Table 2). However, general
knowledge of zoonotic diseases, case reports, and limited research
involving animals in healthcare facilities indicate cause for
concern. 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.
2
MRSA is
just one of many potential pathogens; a wide range of pathogens
exist, including common healthcare-associated pathogens (eg,
Clostridium difficile, multidrug-resistant enterococci), emerging
infectious diseases (eg, extended spectrum β-lactamase (ESBL)–
producing Enterobacteriaceae), common zoonotic pathogens
(eg, Campylobacter, Salmonella, and dermatophytes), rare but
devastating zoonotic pathogens (eg, rabies virus), and pathogens
associated with bites and scratches (eg, Pasteurella spp.,
Capnocytophaga canimorsus, and Bartonella spp.).
2–7
This white paper represents an effort to analyze the available
data and provide rational guidance for the management of
animals in acute care and ambulatory medical facilities,
including animal-assisted activities, service animals, research
animals, and personal pet visitation. It describes the need for
future studies to close the gaps in knowledge about animals in
healthcare settings.
The term guidance deserves special emphasis: this document
should not be viewed as an evidence-based guideline but as a
set of practical, expert-opinion–based recommendations for a
common healthcare epidemiology question, made in the
absence of robust evidence to support practice. Much of the
content is informational and most of the recommendations
in this document should be viewed as suggested actions to
consider in the absence of a recognized standard or regulation.
Adoption and implementation is expected to occur at the
discretion of individual institutions. When clear regulatory or
legislative mandates exist related to AHC (eg, Americans with
Disabilities Act), they are noted. Previous guidelines that have
covered some of the issues addressed in this document include
the “Guidelines for animal-assisted interventions in healthcare
facilities”
3
and the “Centers for Disease Control and Prevention
(CDC)/Healthcare Infection Control and Prevention Advisory
Committee Guidelines for Environmental Infection Control in
Health-Care Facilities.”
8
In this document, we use the following definitions:
1. Animal-assisted activities: pet-therapy, animal-assisted
therapy, and other animal-assisted activities. While these
practices and their purposes may vary because these ani-
mals and their handlers are (or should be) specifically
trained, they will be referred to as animal-assisted activities
animals in this document.
table 1. Selected Diseases Transmitted by Dogs Stratified by Transmission Route
Transmission Route Selected Diseases
Direct contact (bites) Rabies (rabies virus)
Capnocytophaga canimorsus infection
Pasteurellosis (Pasteurella spp.)
Staphylococcus aureus, including methicillin-resistant strains
Streptococcus spp. Infection
Direct or indirect contact Flea bites, mites
Fungal infection (Malassezia pachydermatis, Microsporum canis, Trichophyton mentagrophytes)
Staphylococcus aureus infection
Mites (Cheyletiellidae, Sarcoptidae)
Fecal-oral Campylobacteriosis (Campylobacter spp.)
Paratyphoid (Salmonella spp.)
Giardiasis (Giardia duodenalis)
Salmonellosis (Salmonella enterica subsp enterica serotypes)
Droplet Chlamydophila psittaci
Vector-borne Ticks (dogs passively carry ticks to humans; disease not transmitted directly from dog to human)
▪Rocky Mountain spotted fever (Rickettsia ricksettsii)
▪Ehrlichiosis (Ehrlichia spp.)
Fleas
▪Dipylidium caninum
▪Bartonella henselae
2 infection control & hospital epidemiology

2. Service animals: specifically defined in the United States
under the Americans with Disabilities Act (ADA).
9
3. Research animals: animals approved for research by the facility’s
Institutional Animal Care and Use Committee (IACUC).
4. Personal pet visitation: defined as a personal pet of a patient
that is brought into the facility specifically to interact with
that individual patient.
Intended Use
This document is intended to help acute care hospitals and
ambulatory care facilities develop or modify policies related
to animals based on their role (ie, animal-assisted activities,
service animals, research animals, and personal pet visitation).
It is not intended to guide the management of animals in other
healthcare facilities such as assisted living, nursing homes, or
extended care facilities.
Society for Healthcare Epidemiology of America (SHEA)
Writing Group
The writing group consists of members of the SHEA Guide-
lines Committee, including those with research expertise on
this topic, and invited members with related expertise in legal
affairs, veterinary medicine, and infectious diseases.
Key Areas Addressed
We evaluated and summarized the literature and surveyed
current practices in healthcare institutions around four major
aspects of AHC:
1. Animal-assisted activities
2. Service animals
3. Animals in research
4. Personal pet visitation
table 2. Studies of Pathogens and Outbreaks Associated with Animals in Healthcare (AHC)
Author, Year, (Ref. No.) Methodology Findings
Lefebvre, 2006 (64) Healthy visitation dogs (n, 102) assessed for
presence of zoonotic pathogens.
Zoonotic agents isolated from 80 percent of animals
including: toxigenic Clostridium difficile (40.1%),
Salmonella spp. (3%), extended spectrum beta-
lactamase or cephaloporinase E. coli (4%), Pasteurella
spp. (29%), Malassezia pachydermatis (8%), Toxocara
canis (2%), and Ancylostoma caninum (2%)
Scott, 1988 (65) Epidemic of methicillin-resistant
Staphylococcus aureus (MRSA) on a
rehabilitation geriatric ward
Paws and fur of a cat that roamed the ward were heavily
colonized by MRSA, and the cat was considered to be
a possible vector for the transmission of MRSA
Lyons, 1980 (66) Outbreak of Salmonella Heidelberg in a hospital
nursery
Outbreak traced to infected calves on a dairy farm
where the mother of the index patient lived
Richet, 1991 (67) Outbreak of Rhodococcus (Gordona) bronchialis
sternal surgical site infections after coronary
artery bypass surgery
Outbreak linked to a nurse whose hands, scalp, and
vagina were colonized with the epidemic pathogen.
Although cultures of neck-scruff skin of 2 of her 3
dogs were also positive, whether the animals were the
source for colonizing the nurse or whether both the
animals and nurse were colonized from an
environmental reservoir could not be determined.
Chang, 1998 (68) An evaluation of a large outbreak of Malassezia
pachydermatis in an intensive care nursery
Isolates from all 15 case patients, 9 additional colonized
infants, 1 healthcare worker, and 3 pet dogs owned by
HCP had identical patterns of restriction fragment-
length polymorphisms (RFLPs).
The authors believed it likely that M. pachydermatis was
introduced into the intensive care nursery from the
healthcare worker’s hands after being colonized from
pet dogs at home and then persisted in the nursery
through patient-to-patient transmission.
Patient infections were not benign and included 8
bloodstream infections, 2 urinary tract infections,
1 case of meningitis, and 4 asymptomatic
colonizations.
Mossovitch, 1986 (69),
Snider, 1993 (70)
Multiple nosocomial outbreaks of Microsporum
canis (ringworm) in newborn nurseries or
neonatal intensive care units.
Person-to-person transmission described; in neonatal
intensive care unit outbreak, the source of infection
in the neonatal intensive care unit outbreak was a
nurse likely infected from her pet cat.
shea expert guidance: animals in healthca re facilities 3

Guidance and Recommendation Format
Because this topic lacks the level of evidence required for a
more formal guideline using the GRADE
10
or a similar system
for quantitating scientific papers, no grading of the evidence
level is provided for individual recommendations. Guidance
statements are provided for each of the sections identified in
our review. Each guidance statement is based on a synthesis of
the limited available evidence, theoretical rationale, practical
considerations, analysis from a survey of SHEA membership
and the SHEA Research Network, writing group opinion, and
consideration of potential harm where applicable.
review of submitted policies and
procedures healthcare facilities
We reviewed and compared hospital policies that were
submitted from various institutions by the writing group and
members of the SHEA Guidelines Committee and summar-
ized the policies and procedures submitted by 23 healthcare
facilities.
Animal-Assisted Activities (Animal-Assisted or “Pet
Therapy”Programs)
Of the 23 facility policies submitted, 20 mentioned specific
recommendations regarding animal-assisted activities. Most
policies defined an animal-assisted activities animal as a per-
sonal pet that, with its owner or handler, provides comfort to
patients in healthcare facilities. Dogs were almost exclusively
utilized in animal-assisted activities; however, three policies
allowed cats or miniature horses as animal-assisted activities
animals. In general, animal-assisted activities animals were
required to be >1–2 years of age, be fed a fully cooked diet for
the preceding 90 days, not be in estrus, have lived with their
owner in a residence for >6 months, and be housebroken, well
mannered, obedient, easily controlled by voice command, and
restrained by a short (4–6 feet) leash or lead. Eight policies
required animals to be bathed and groomed within 24 hours
prior to each visit, including brushing and filing of nails.
A total of 12 policies required a nationally or regionally
recognized organization to approve the animal for registration
and certification of its training as an animal-assisted activities
animal. Almost all policies required that the animals undergo
regular (usually annual) evaluation by a veterinarian con-
firming their good health, that they be up-to-date on vacci-
nations, and that they have normal laboratory work (2 policies
required routine negative stool cultures prior to participation).
Animal-assisted activities animals and handlers were routinely
provided hospital-specific photo identification and uniforms
identifying them as an animal-assisted activities team.
Some policies specifically excluded certain patients from
animal-assisted activities (Table 3). These 14 policies required
staff members, visitors, and patients to perform hand hygiene
both prior to and after interacting with animal-assisted activities
animals. Some policies stated that during animal-assisted
activities, a barrier such as a sheet or towel be placed between
the animal and the patient, either on the bed over the bedding,
on a chair, or on a lap. In addition, the animal-assisted activ-
ities animal handler was usually responsible for cleaning up
after any potential spills or environmental contamination
during a therapy animal visit.
Service Animals
A total of 18 hospitals submitted their policies on service
animals (Table 4). Most policies mentioned that service animals
are not pets, and a few institutions specified that comfort and
companionship animals are not service animals. Although
most policies specifically allowed dogs, some also allowed the
use of cats and miniature horses. A few institutions considered
emotional support and seizure alert animals to be service
animals.
Requirements of service animals consistently included
up-to-date vaccinations and certification of good health, and
that service animals are required to be housebroken and under
the control of the handler at all times, usually with a leash.
Further, a physician order and permission from the Infection
Prevention and Control Department were often required. In
general, service animals were prohibited from drinking out of
public water areas (eg, toilets, sinks), from having contact
with persons with non-intact skin, and being kept overnight.
Most policies clearly stated that care of the service animal was
the complete responsibility of the patient, or his or her
designee. Areas that policies often listed as off-limits included
operating rooms, post-anesthesia areas, heart and vascular
procedure rooms, intensive care units, family birthing areas,
pharmacy, central sterile processing, food preparation areas,
nurseries, medication rooms, diagnostic areas, dialysis units,
playrooms, rooms where the patient has a roommate, rooms
that house patients with documented animal allergies or
phobias, and around patients with altered mental status or
post-splenectomy patients. The policies for visitors with
service animals were similar to those applicable to patients,
although some healthcare facilities chose to prohibit service
animals of visitors from intensive care units, oncology and
transplant units, and from visiting patients on isolation
table 3. Exclusion Criteria Cited by Hospital Policies Related to
Animal-Assisted Activities
Type of Patient
Policies Citing Listed
Exclusion Criteria
(n =20), No. (%)
Isolation (contact/airborne/droplet, etc.) 12 (60)
Immunocompromised (definitions varied) 6 (30)
Allergy to animals 5 (25)
Fear of animals 5 (25)
Open wounds 4 (20)
Behavior or psychiatric disorder 1 (5)
4 infection control & hospital epidemiology

precautions. Many policies required immediate reporting of any
injuries to the appropriate HCP (eg, risk management).
Research Animals
Only one-third of the policies discussed research animals.
Those noted that although it is sometimes necessary for
research animals to be present in patient care areas, every effort
must be made to minimize interactions between the animals,
HCP, and patients. These policies stated that all animal
research must be approved by the institution’s IACUC and,
when research animals must be present in patient care areas,
animal visits must be scheduled to minimize overlap with
patient care activities. Policies also detailed how animals
should be transported safely in the facility. For example, small
animals should be caged and covered with drapes or opaque
material. Other recommendations said that animals should
only be transported in service elevators not utilized by patients.
In cases where macaque nonhuman primates are research ani-
mals, one policy recommended that a bite and scratch kit and a
copy of the CDC guideline on treatment of herpes B virus
accompany the animals.
11
Policies reinforced the importance of
comprehensive record keeping and appropriate waste disposal,
noting that the principal investigator is ultimately responsible
for these tasks. Policies varied on internal notification (eg,
Infection Prevention and Control, Safety Compliance office).
Personal Pet Visitation
A total of 13 policies allowed personal pet visitation (Table 5).
Some had no restrictions, while others stipulated that visita-
tion could occur only under exceptional (compassionate)
circumstances. Most of these institutions explicitly barred
certain pets from visitation, including animals recently adopted
fromshelters,rodents,birds,reptiles,andamphibians.Some
required that pets be at least 1–2 years of age and have resided in
the patient’s household for at least 6–12 months. While most
institutions outlined prerequisites necessary to allow personal
pet visitation, some only required permission from the nursing
manager and attending physician. Some also required final
approval by Infection Prevention and Control (IPC). Four
institutions required veterinarian approval.
table 4. Summary of Responses from Hospitals Submitting Policies and Procedures on Service Animals
Situation Hospitals (n =18), No. (%)
Policies specified that service animals be allowed in all areas where individuals
would normally be allowed, except in areas where isolation precautions are
in place or where the animal’s presence may compromise patient care (eg,
operating room (OR), intensive care unit, behavioral health).
18 (100)
Policy specified type of service animals, usually dogs 15 (83)
including 2 institutions that allowed cats for seizure alerts or
emotional support
Policy allowed use of animals for seizure alerts or anxiety related to PTSD 6 (33)
Policy included specific questions that could be asked if the facility is unsure
whether an animal is a service animal: (1) whether the animal is required
because of a disability, and (2) what work or tasks the animal has been
trained to perform (however, some policies indicated that asking about the
specific training is against the American Disabilities Act (ADA)
recommendations)
8 (44)
Policy stated that proof is not required whether an animal is designated as a
service animal
9 (50)
1 institution each: requires veterinarian’s certificate of good
health and immunizations; wear tag evidencing vaccination and
for dogs, license tags; provide identification of service animal as
available and validation of current rabies vaccination
Policy stated that comfort or companionship animals do not qualify as service
animals
7 (39)
Policy outlined situations when service animals can be removed (eg, animals
that are out of control, disruptive to patient care, not housebroken, and
have behavior problems)
11 (61)
Policy outlined provisions when owner or owner’s family/friends are unable
to care for service animal
5 (28)
Policy clearly stated that care of service animal is the responsibility of the
patient (or designee)
15 (83)
Policy required that the service animal be on a leash or harness at all times,
unless these devices would interfere with the service animals’work or cause
interruption of patient care
9 (50)
shea expert guidance: animals in healthca re facilities 5

survey of shea membership on animals
in healthcare
We conducted a survey of the SHEA Membership and SHEA
Research Network from February through May 2013 and
summarized responses from members’institutions about
existing policies related to AHC.
Survey Results
A total of 337 SHEA members and members of the SHEA
Research Network (21.7% response of 1,550 members)
responded to the survey regarding their institutions’policies
for AHC (Table 6). The survey included questions regarding
4 situations in which animals would be encountered in the
healthcare facility: animal-assisted activities (animal-assisted
therapy programs/“pet therapy”), service animals, research
animals, and personal pet visitation. The majority of respon-
dents worked at acute care hospitals (93%). Additional
facilities included freestanding children’s hospitals (4%),
freestanding clinics (1%), and other facility types (2%) such as
specialty hospitals, research hospitals, and rehabilitation hos-
pitals. The majority of responses were from university/teach-
ing hospitals (40%) or university/teaching-affiliated hospitals
(26%) and non-teaching hospitals (24%). We received addi-
tional responses from Veterans Affairs and other government
hospitals (4%), free-standing pediatric hospitals (4%), teach-
ing non-university affiliated hospitals, and miscellaneous
facilities (2%). Most of the respondents were from US facilities
(77%) with representation from Canada (2%), Latin America
(3%), Europe (3%), Asia (3%), Middle East (1%) and other
regions (1%), while 10% did not identify their region. Of the
43 non-US respondents, only 24 were linked to institution-
identifying information; consequently, data from only these 24
institutions were analyzed.
Not all responding healthcare facilities with animal pro-
grams had formal policies. The following is the percentage of
facilities that allowed animals but had no formal policy:
animal-assisted activities (5.8%, 18 of 306), service animals
(4.3%, 12 of 279), research animals (8.5%, 11 of 130), personal
pet visitation (5.8%, 7 of 121). Infection Prevention and
Control frequently administered policies, with participation by
human resources and legal services. Notably, 8 US facilities,
including a Veteran’s Hospital, reported that they did not
allow service animals.
A total of 315 responses (93.5%) addressed questions
regarding the presence of animals in specific areas of the
hospital. Almost all facilities restricted animals from the
operating room, kitchen, central processing, and pharmacy
(Table 7). Overall, 3 US facilities and 3 unidentified facilities
had no restrictions; some cited the ADA as the reason.
table 5. Summary of Policy Requirements for Personal Pet Visitation
Situation Institutions (N =23), No. (%)
Did not allow personal pets 4/23 (17)
No response or did not submit policy and procedure 6/23 (26)
Allowed personal pets 13/23 (54)
Allowed only dogs and cats 6/13 (46)
Allowed dogs only 2/13 (15)
Specified age (>1–2 y/o) and duration of ownership (>6–12 mo) 5/13 (38)
Did not specify type of pets 5/13 (38)
Excluded many types of animals 3/13 (23)
Visitation prohibited for patients in isolation, ICU, or immunocompromised 6/13 (46)
Case-by-case determination 8/13 (44)
Allowed pets for extenuating circumstances 6/13 (46)
Specified duration of visitation (1–2 hr) 5/13 (38)
Required certification of pet’s immunization status and good health 5/13 (38)
NOTE. ICU, intensive care unit.
table 6. Allowable Uses of Animals in Healthcare (AHC) Facilities, Stratified by 4 Major Categories
Service Animals,
No. (%)
Animal-Assisted Activities,
No. (%)
Personal Pet Visitation,
No. (%)
Research Animals,
No. (%)
Responses, No. (%) Yes No NA Yes No NA Yes No NA Yes No NA
US facilities 280 (83) 267 (95) 8 (3) 5 (2) 249 (89) 24 (9) 7 (3) 113 (40) 158 (57) 9 (3) 99 (35) 155 (56) 26 (9)
Non-US facilities 24 (7) 20 (83) 4 (17) 0 16 (67) 7 (29) 1 (4) 5 (20) 18 (75) 1 (5) 14 (58) 9 (38) 1 (4)
Unknown 33 (10) 19 (58) 10 (30) 4 (12) 14 (42) 15 (46) 4 (12) 3 (9) 26 (79) 4 12) 17 (52) 10 (30) 6 (18)
Total 337 (100) 306 (90) 22 (7) 9 (3) 279 (82) 46 (14) 12 (4) 121 (36) 202 (60) 14 (4) 130 (38) 174 (52) 33 (10)
NOTE. NA, not available.
6 infection control & hospital epidemiology

All facilities (279) that permitted animal-assisted activities
allowed dogs, with 21% of facilities also allowing cats, 5%
allowing miniature horses, and 2% allowing primates.
In summary, our review of institutional policies and of the
survey results demonstrated substantial variation in practice
around the issues related to AHC.
Guidance Statement
See Table 8 for summary of AHC classification and selected
key recommendations from this document.
animal-assisted activities
Background
The origins of animal-assisted activities remain obscure but
seem to revolve around the “attachment theory”of Sigmund
Freud and may have initially been practiced in 19
th
Century
England.
12
In 1919, dogs were used in therapeutic intervention
with psychiatric patients at St. Elizabeth Hospital in
Washington, DC.
13
Since then, there have been increasing
roles for AHC facilities. There are several categories of activities
in which animals may be used with minor differences in
definitions that often overlap:
1. Animal-assisted therapy, which includes animals as part of
a specific treatment program.
2. Animal-assisted education (AAE), which includes goal-
directed interventions designed to promote improvement
in cognitive functioning of the person(s) involved and
in which a specially trained dog and handler team is an
integral part of an educational process.
3. Animal-assisted activities that include programs for visita-
tion in hospitals that use specially trained animals and their
handlers. Animal-assisted activities may include recrea-
tional and social purposes or goal-directed interventions
in which an animal is involved as part of an organized
treatment process, which may provide opportunities for
motivational, educational, and/or recreational benefits to
enhance a person’s quality of life.
4. Animal visitation programs and “pet therapy”are inter-
changeable terms and are incorporated into the more
general category of animal-assisted activities for the purposes
of this document.
While individual institutions may have specific programs
involving animals in the hospital, the vast majority of hospitals
have “animal-assisted activities”as defined in this document.
table 7. Areas of Healthcare Facility In Which Animals Were
Prohibited (Responses =315)
Area in Healthcare Facility
Percent of Facilities Prohibiting Animals
from Respective Areas, No. (%)
Intensive care unit 230 (73)
Operating room 293 (93)
Kitchen 211 (67)
Pharmacy 280 (89)
Step-down units 123 (39)
Recovery room 271 (86)
Central processing 290 (92)
table 8. Summary of Animals in Healthcare Classification and Selected Recommendations
Animal-Assisted
Activities Service
a
Research Personal Pet
Program
Written policy recommended Yes Yes Yes Yes
Federal legal protection No Yes No No
Animal visit liaison Yes No IACUC Yes
Infection prevention and control notification of animal visit/session Yes Yes Yes Yes
Infection prevention and control consultation for restricted areas Yes Yes Yes Yes
Visit supervised Yes No Yes Yes
Visit predetermined Yes No Yes Yes
Animal and handler/owner performs trained tasks See text Yes N/A No
Specially trained handler Yes Yes Yes No
Health screening of animals and handlers Yes N/A N/A No
Documentation of formal training Yes No N/A No
Animal can be a pet Yes No No Yes
Animal serves solely for comfort or emotional support See text No N/A Yes
Identification with ID tag Yes Not required N/A Yes/No
Animal required to be housebroken Yes Yes N/A Yes
Permitted animals
Dogs Yes Yes N/A Yes
Other animals See text See text N/A See text
NOTE. IACUC, Institutional Animal Care and Use Committee.
a
Policy to reflect ADA and regulatory compliance. Inquiries limited by ADA to tasks performed for patient.
shea expert guidance: animals in healthcare facilities 7

Several published studies promote animal-assisted activities to
improve psychological health, pain management, and lowering
of blood pressure among patients and staff (Table 9). Most of
these studies, though not scientifically rigorous, provide evi-
dence of beneficial impacts on various patient populations
from animal-assisted activities. In a review of “pet-facilitated
therapy”as an aid to psychotherapy, Draper et al
14
noted
that although a literature review conducted in 1987 revealed
more than 1,000 articles on the human-animal bond, only 6
controlled studies evaluating the therapeutic value of animal-
assisted activities had been reported as of 1983. These studies
concluded that the benefits of animal-assisted activities relied
heavily on anecdotal reports and the widespread attachment of
persons with animals. In a critical appraisal of the literature
from 1986 through 1997, Allen
15
concluded that most reports
describing the effects of human-canine interactions fell into
the lowest category of scientific studies (ie, descriptive studies
and expert opinion). Newer research, sometimes using con-
trolled trials, has provided evidence that companion animals
provide health benefits in the home setting.
16
An increasing
number of clinical trials are evaluating the benefits of animal-
assisted activities in the hospital (Table 9). Recently the
American Heart Association (AHA) published a scientific
statement regarding pet ownership and cardiovascular risk and
concluded that pet ownership, particularly dog ownership, “is
probably associated with”and “may have some causal role”in
decreased cardiovascular disease risk. While not specifically
reviewing animal-assisted activities, this endorsement by a
major professional organization is noteworthy.
Differences Between Animal-Assisted Activities Animals and
Service Animals
Animal-assisted activities animals and their handlers are trained
to provide specific human populations with appropriate contact
with animals.
17
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.
Animal-assisted activities animals must meet specificcriteriafor
health, grooming, and behavior, and their access can be
restricted at the discretion of the facility. Animal-assisted activ-
ities 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 animal-assisted activities animals.
Guidance (Animal-Assisted Activities)
I. Overview of management of an animal-assisted activities
program within a healthcare facility.
A. Facilities should develop a written policy for animal-
assisted activities.
B. An animal-assisted activities visit liaison should be desig-
nated to provide support and facilitate animal-assisted
activities visits. Often these visits are managed by the
facility’s Volunteer Office or Department.
C. Only dogs should be used (ie, exclude cats and other
animals). Cats should be excluded because they cannot be
trained to reliably provide safe interactions with patients in
the healthcare setting.
D. Animals and handlers should be formally trained and
evaluated. Facilities should consider use of certification
by organizations that provide relevant formal training
programs (eg, Pet Partners, Therapy Dogs Incorporated,
Therapy Dogs International). Alternatively, facilities
should designate responsibility for the program elements
to an internal department (eg, volunteer department) to
verify all elements (see section III).
E. Animals and animal handlers should be screened prior to
being accepted into a facility animal-assisted activities
program (see section II)
F. The IPC should be consulted regarding which locations are
appropriate for animals interacting with patients.
G. All clinical staff should be educated about the animal-
assisted activities program, its governance, and its policies.
II. Training and management of animal-assisted activities
handlers. Facilities should do the following:
A. Ensure that animal-assisted activities handlers have been
informed of the facility’s IPC and human resource policies
(similar to volunteers) and have signed an agreement to
comply with these policies.
B. Confirm that animal-assisted activities handlers have been
offered all immunizations recommended for healthcare
providers (HCP) within that facility (eg, measles, mumps,
and rubella, varicella, pertussis, influenza). If immunization
is required of HCP, it should be required for animal-assisted
activities handlers.
C. Require the animal-assisted activities handler to escort the
animal to the destination as arranged by the facility’s animal-
assisted activities liaison and following hospital policy.
D. Instruct the animal-assisted activities handler to restrict
contact of his or her animal to the patient(s) being visited
and to avoid casual contact of their animal with other
patients, staff or the public.
E. Limit visits to 1 animal per handler.
F. Require that every animal-assisted activities handler parti-
cipate in a formal training program and provide a certifi-
cate confirming the training, which includes modules on
the following:
1. Zoonotic diseases
2. Training on standard precautions including hand hygiene
before and after patient contact
3. Proper cleaning and disinfection of surfaces contaminated
by animal waste (urine or feces)
4. Proper disposal of animal waste
5. Visual inspection for ectoparasites
6. Reading of an animal’s body language to identify signs of
physical discomfort, stress, fear, or aggression
7. Identification of appropriate contacts in the event of an
accident or injury
8 infection control & hospital epidemiology

table 9. Review of Selected References on Animal-Assisted Activities
Author, Year, (Ref. No.) Type Methodology Findings
Abate SV, 2011 (71) Hospitalized heart-
failure patients
Subjects were provided the opportunity to
participate in canine-assisted
ambulation (walking with a therapy
dog). Case subjects were compared with
a historical population of
537 controls.
Distance ambulated increased from
120.2 steps in a randomly selected,
stratified historical sample to 235.07
in the canine-assisted ambulation
study sample (P<.0001). Subjects
unanimously agreed that they enjoyed
canine-assisted ambulation and
would like to participate in canine-
assisted ambulation again.
Banks MR, 2002 (72) Long-term care Randomized clinical trial, three groups of
15 patients (no animal-assisted therapy;
animal-assisted therapy once/week;
animal-assisted therapy 3x/week);
pre-post assessment
Residents volunteering for the study had
a strong life-history of emotional
intimacy with pets.
AAA significantly reduced loneliness
scores in comparison with the no
animal-assisted therapy group.
Barak Y, 2001 (73) Psychiatric ward Randomized clinical trial of 20 patients,
10 with and 10 without animal-assisted
therapy
Improvement was noted in both groups
compared with baseline scores and
were significantly more positive for
the AAA group on both Total Social
Adaptive Functioning Evaluation
score and on the Social Functions
subscale.
Barker SB, 2003 (74) Fear in electroconvulsive
therapy (ECT)
35 patients were assigned on alternate days
to a 15-min animal-assisted therapy
session (intervention), or 15-min
session with magazines (control)
Animal-assisted therapy reduced fear
and anxiety but had no demonstrated
effect on depression.
Barker SB, 1998 (75) Psychiatric patients Self-reported, pre- and post-treatment
crossover study that compared the
effects of a single animal-assisted
therapy session with those of a single
regularly scheduled therapeutic
recreation session.
Reductions in anxiety scores were found
after the animal-assisted therapy
session for patients with psychotic
disorders, mood disorders, and other
disorders. No significant differences
found in reduction of anxiety.
Beck CE, 2012 (76) Outpatient veterans Animal-assisted therapy on Warriors in
Transition (N =24) attending an
Occupational Therapy Life Skills
program; pre-test, post-test
nonrandomized control group study
Differences were not found between the
groups on most measures; subjective
reports of satisfaction with AAA.
Brodie SJ, 1999 (77) Review Potential benefits of pet therapy are
considerable and nurses may assume
an active role in advocating ward pet
or pet-visiting schemes.
Chu CI, 2009 (78) Taiwanese inpatients
with schizophrenia
30 participants were randomly assigned to
either a weekly animal-assisted
activities program for 2 mo (treatment)
or no animal contact (control).
The treatment group showed significant
improvement on all measures except
for social support and negative
psychiatric symptoms.
Cole KM, 2007 (79) Hospitalized heart-
failure patients
3-group randomized repeated-measures
experimental design was used in 76
adults: group 1 received a 12-minute
visit from a volunteer with a therapy
dog; group 2, a 12-min visit from a
volunteer; and the control group, usual
care.
Animal-assisted therapy improved
cardiopulmonary pressures,
neurohormone levels, and anxiety in
patients hospitalized with heart
failure.
Edwards NE, 2002 (80) Alzheimer’s disease Evaluated effects of fish aquariums on
nutritional intake in individuals with
Alzheimer’s disease in 62 patients.
Nutritional intake increased significantly
when the aquariums were introduced.
shea expert guidance: animals in healthcare facilities 9

table 9. Continued
Author, Year, (Ref. No.) Type Methodology Findings
Edwards NE, 2014 (81) Aquaria in long-term
care dementia
Pre-post test design—3 units, 71
individuals with dementia and 71
professional staff.
Residents’behaviors improved along
four domains: uncooperative,
irrational, sleep, and inappropriate
behaviors.
Jorgenson J, 1997 (82) Review Benefits of the animal-human bond may
include decreased blood pressure,
heart rates, and stress levels, as well as
increases in emotional well-being and
social interaction.
Kamioka H, 2014 (83) Review of randomized controlled trials
from 1990 to October 31, 2012;
11/57 studies met criteria for analysis
Randomized clinical trials relatively low
quality and heterogeneity precluded
meta-analysis. In a study environment
limited to people who like animals,
animal-assisted therapy may be an
effective treatment for mental and
behavioral disorders.
Levine GN,2013 (84) American Heart
Association scientific
statement
Review of 36 studies Pet (particularly dogs) ownership may
have some causal role in reducing
cardiovascular disease risk.
Marcus DA 2013 (85) Literature review and
rationale
Review of 6 studies Dog therapy visits reduced pain and
pain-related symptoms.
Moretti F, 2011 (86) Nursing home patients
with dementia,
depression and
psychosis.
Mini-Mental State Examination (MMSE)
and Geriatric Depression Scale (GDS)
administered to 10 animal-assisted
activities patients and 11 controls
before and after a 6-week pet therapy
intervention.
Improved depressive symptoms and
cognitive function in residents of
long-term care facilities with mental
illness.
Nepps P, 2014 (87) Community hospital
mental health unit
218 patients on mental health unit of a
community hospital with an existing,
complementary animal-assisted
activities program. Half of the patients
participated in a 1-h session of animal-
assisted activities and comparison
group in a 1-h stress management
program.
Significant decreases (P<.05) in
depression, anxiety, pain, and pulse
after animal-assisted activities
program, compared to those in the
more traditional stress management
group.
Nordgren L, 2014 (88) Dementia patients 6-month study of 33 residents of Swedish
nursing homes with dementia (20 in
the intervention group; 13 in the
control group). Assessment of the
effects of a dog-assisted intervention on
behavioral and psychological
symptoms. The intervention comprised
ten sessions (45–60 min, 1–2 × /week).
Some positive tendencies were observed.
Dog-assisted intervention may
provide an alternative or a
complement to pharmacological
treatments to reduce behavioral
symptoms in people with dementia,
but its value and place in care require
further evaluation.
Sobo EJ, 2006 (89) Pediatric hospital Pre-post mixed-methods survey in
pediatric hospital (25 patients)
Pet visitation reduced perceived pain.
Swall A, 2014 (90) Alzheimer’s disease Video recorded sessions were conducted
for each visit of the dog and its handler
to a person with Alzheimer’s disease.
Time spent with the dog shows the
person recounting memories and
feelings, and enables an opportunity
to reach the person on a cognitive
level.
Willis DA, 1997 (91) Review Animals can promote feelings of self-
worth, help offset loneliness, reduce
anxiety, provide contact, comfort,
security, and the feeling of being
needed.
10 infection control & hospital epidemiology

G. Require that a handler use particular care in directing the
visit to prevent patients from touching the animal in
inappropriate body sites (eg, mouth, nose, perianal region)
or handling the animal in a manner that might increase the
likelihood of frightening or harming the animal or the
animal accidentally or intentionally harming the patient.
H. Restrict visiting sessions to a maximum of 1 hour to reduce
the risk of adverse events associated with animal fatigue.
1. Handlers must observe the animal for signs of fatigue,
stress, thirst, overheating, or urges to urinate or defecate.
a. If taking a short break (or taking the animal outside to
relieve it) does not ease the animal’s signs of discomfort,
then the session should be terminated for that day.
2. Handlers must comply with facility-defined restrictions for
patient visits and be familiar with facility-specific signage
regarding restricted areas or rooms.
I. Require that all animal handlers observe standard occupa-
tional health practices. Specifically, they should self-screen
for symptoms of communicable disease and refrain from
providing animal-assisted activities services while ill. Such
symptoms include, but are not limited to the following:
1. New or worsening respiratory symptoms (ie, cough,
sneezing, nasal discharge)
2. Fever (temperature >38°C)
3. Diarrhea or vomiting
4. Conjunctivitis
5. Rash or non-intact skin on face or hands
J. Require that handlers keep control of the animal at all
times while on the premises, including the following:
1. Keeping a dog leashed at all times unless transported
within the facility by a carrier (as may be the case with
smaller breeds).
2. Refraining from using cell phones or participating in other
activities that may divert his/her attention away from the
animal.
K. Require all handlers to manage their animal as follows:
1. Approach patients from the side that is free of any invasive
devices (eg, intravenous catheters) and prevent the animal
from having contact with any catheter insertion sites,
medical devices, breaks in the skin, bandage materials, or
other compromised body site.
2. Before entering an elevator with an animal, ask the other
passengers for permission, and do not enter if any
passenger expresses reluctance or appears apprehensive.
3. Require that everyone who wishes to touch the animal
practice hand hygiene before and after contact.
4. Do not permit a patient to eat or drink while interacting
with the animal.
5. Restrict the animal from patient lavatories.
6. In the case of an animal’s urinary or fecal accident,
immediately terminate the visit and take appropriate
measures to prevent recurrence during future visits.
a. If submissive urination was involved, this will require
suspending the animal’s visiting privileges, having the
handler address the underlying cause, and then formally
reevaluating the animal’s suitability before visiting privileges
are restored.
b. If repeated incidents of this nature occur, permanently
withdraw the animal’s visiting privileges.
c. In the case of vomiting or diarrhea, terminate the visit
immediately and withdraw the animal from visitation for a
minimum of 1 week.
7. Report any scratches, bites, or any other inappropriate
animal behavior to healthcare staff immediately so that
wounds can be cleaned and treated promptly. Report any
injuries to the animal-assisted activities liaison as soon as
possible and to public health or animal control authorities,
as required by local laws.
a. The visit should be immediately terminated after any bite or
scratch.
b. In the case of bites, intentional scratches, or other serious,
inappropriate behavior, permanently withdraw the animal’s
visiting privileges.
c. In the case of accidental scratches, consider the circum-
stances that contributed to the injury and take appropriate
measures to prevent similar injuries from occurring in
the future. If measures cannot be taken to reduce the
risk of recurrence, then visitation privileges should be
withdrawn.
d. If it is determined that the handler’s behavior was
instrumental in the incident, then the handler’s visitation
privileges should be terminated until the animal-assisted
activities program manager has addressed the situation.
e. Report any inappropriate patient behavior (eg, inappropriate
handling, refusal to follow instructions) to the animal visit
liaison.
L. Facilities should maintain a log of all animal-assisted
activities visits that includes rooms and persons visited for
potential contact tracing.
III. Requirements of acceptable animals for animal-assisted
activities programs
A. Allow only domestic companion dogs to serve as animal-
assisted activities animals. Cats are not included in the
recommendation due to concerns for increased potential
allergenicity, potential increased risk of bites and scratches,
and lack of data demonstrating advantages over dogs.
1. Allow only adult dogs (ie, dogs of at least 1 year but ideally
at least 2 years of age, the age of social maturity).
2. Deny the entry of dogs directly from an animal shelter or
similar facility.
3. Require that dogs be in a permanent home for at least
6 months prior to enrolling in the program.
4. Admit a dog only if it is a member of a formal animal-
assisted activities program and is present exclusively for the
purposes of animal-assisted activities.
shea expert guidance: animals in healthca re facilities 11

B. Require that every dog pass a temperament evaluation
specifically designed to evaluate it under conditions that
might be encountered when in the healthcare facility.
Such an evaluation should be performed by a designated
evaluator.
1. Typically, this evaluation will assess, among other factors,
reactions toward strangers, loud and/or novel stimuli, angry
voices and potentially threatening gestures, being crowded,
being patted in a vigorous or clumsy manner, reaction to a
restraining hug, interactions with other animals, and the
ability to obey handler’s commands.
C. Require all evaluators (either at facility or at the formal
certification program) to successfully complete a course or
certification process in evaluating temperament and to
have experience in assessing animal behavior and level of
training.
1. Require all evaluators to have experience with animal
visiting programs or, at the very least, appreciate the
types of challenges that animals may encounter in the
healthcare environment (eg, startling noises, crowding,
rough handling).
2. If several animals need to be evaluated for behaviors other
than reactions to other animals, require that the tempera-
ment evaluator assess each animal separately, rather than
assessing several animals simultaneously.
D. Recommend that animal-handler teams be observed by an
animal-assisted activities program liaison at least once in a
healthcare setting before being granted final approval
to visit.
E. Recommend that each animal be reevaluated at least every
3 years.
F. Require that any animal be formally reevaluated before
returning to animal-assisted activities after an absence of
>3 months.
G. Require that a handler suspend visits and have his or her
animal formally reevaluated whenever he or she notices or is
apprised (either directly or through the animal visit liaison)
that the animal has demonstrated any of the following:
1. A negative behavioral change since the time it was last
temperament tested
2. Aggressive behavior outside the healthcare setting
3. Fearful behavior during visitations
4. Loss of sight or hearing and, consequently, an overt
inclination to startle and react in an adverse manner
H. Health screening of animals
1. Basic requirements for all animals
a. Require that dogs be vaccinated against rabies as dictated by
local laws and vaccine label recommendations. Serologic
testing for rabies antibody concentration should not be
used as a substitute for appropriate vaccination.
b. Exclude animals with known or suspected communicable
diseases.
c. Animals with other concerning medical conditions should
be excluded from visitation until clinically normal (or the
condition is managed such that the veterinarian feels that it
poses no increased risk to patients) and have received a
written veterinary health clearance. Examples include
episodes of vomiting or diarrhea; urinary or fecal incon-
tinence; episodes of sneezing or coughing of unknown or
suspected infectious origin; animals currently on treatment
with non-topical antimicrobials or with any immuno-
suppressive medications; infestation by fleas, ticks, or other
ectoparasites; open wounds; ear infections; skin infections
or “hot spots”(ie, superficial folliculitis or pyoderma); and
orthopedic or other conditions that, in the opinion of the
animal’s veterinarian, could result in pain or distress to the
animal during handling and/or when maneuvering within
the facility.
d. Exclude animals demonstrating signs of heat (estrus)
during this time period.
2. Scheduled health screening of animal-assisted activities
animals
i. Require that every animal receive a health evaluation by a
licensed veterinarian at least once (optimally, twice) per year.
1. Defer to the animal’s veterinarian regarding an appropriate
flea, tick, and enteric parasite control program, which
should be designed to take into account the risks of the
animal acquiring these parasites specific to its geographic
location and living conditions.
2. Routine screening for specific, potentially zoonotic micro-
organisms, including group A streptococci, Clostridium
difficile, VRE, and MRSA, is not recommended.
ii. Special testing may be indicated in situations where the
animal has physically interacted with a known human
carrier, either in the hospital or in the community, or when
epidemiologic evidence suggests that the animal might be
involved in transmission. Testing should be performed by
the animal’s veterinarian in conjunction with appropriate
infection prevention and control and veterinary infectious
disease personnel, if required.
iii. Special testing may be indicated if the animal-assisted
activities animal is epidemiologically linked to an outbreak
of infectious disease known to have zoonotic transmission
potential. Suspension of visitation pending results is
recommended in these situations.
3. Dietary guidelines for all animals
a. Exclude any animal that has been fed within the past
90 days any raw or dehydrated (but otherwise raw) foods,
chews, or treats of animal origin, excluding those that are
high-pressure pasteurized or γirradiated.
IV. Preparing animals for visits:
1. Require that every handler do the following:
i. Brush or comb the animal’s hair coat before a visit to remove
as much loose hair, dander, and other debris as possible.
12 infection control & hospital epidemiology

ii. Keep the animal’s nails short and free of sharp edges.
iii. If the animal is malodorous or visibly soiled, bathe it with
a mild, unscented (if possible), hypoallergenic shampoo
and allow the animal’s coat to dry before leaving for the
healthcare facility.
iv. Visually inspect the animal for fleas and ticks.
v. Clean the animal carrier.
vi. Maintain animal leashes, harnesses, and collars visibly
clean and odor-free.
vii. Use only leashes that are non-retractable and 1.3 to 2 m
(4 to 6 feet) or less in length.
viii. Not use choke chains or prong collars, which may trap
and injure patients’fingers.
ix. Make an animal belonging to an animal-assisted activities
program identifiable with a clean scarf, collar, harness or
leash, tag or other special identifier readily recognizable
by staff.
x. Provide a dog with an opportunity to urinate and defecate
immediately before entering the healthcare facility. Dispose
of any feces according to the policy of the healthcare facility
and practice hand hygiene immediately afterward.
V. Managing appropriate contact between animals and people
during visits
A. Obtain oral or written consent from the patient or his or
her agent for the visit and preferably from the attending
physician as well. Consider documenting consent in the
patient’s medical record.
B. The handler should notify caregiver (eg, nurse or
physician) of the animal visitation.
C. The handler should be required to obtain oral permission
from other individuals in the room (or their agents) before
entering for visitation.
D. All visiting animals should be restricted from entering
the following clinical areas at all times, in addition to non-
clinical areas outlined below in Service Animals section
V.E.2.:
1. Intensive care units; isolation rooms; neonatal and new-
born nurseries; areas of patient treatment where the nature
of the treatment (eg, resulting in pain for the patient) may
cause the animal distress; and other areas identified
specifically by the healthcare facility (eg, rooms of
immunocompromised patients).
E. Require the handler to prevent the animal from coming
into contact with sites of invasive devices, open or
bandaged wounds, surgical incisions, or other breaches in
the skin, or medical equipment.
F. If the patient or agent requests that an animal be placed on
the bed, require that the handler do the following:
1. Check for visible soiling of bed linens first.
2. Place a disposable, impermeable barrier between the animal
and the bed; throw the barrier away after each animal visit.
3. If a disposable barrier is not available, a pillowcase, towel, or
extra bed sheet can be used. Place such an item in the
laundry immediately after use and never use it for multiple
patients.
G. Instruct the handler to discourage patients and HCP from
shaking the animal’s paw. If the dog is trained to shake
hands with a patient and this contact is allowed by facility,
ensure that the patient performs hand hygiene before and
after shaking the animal’s paw.
H. Require the handler to prevent the animal from licking
patients and HCP.
I. Prohibit feeding of treats to animals by HCP; however, if
the act is believed to have a significant therapeutic benefit
for a particular patient, then require that the handler:
1. Ensure that the animal has been trained to take treats
gently.
2. Provide the patient with appropriate treats to give, avoiding
unsterilized bones, rawhides and pig ears, and other
dehydrated and unsterilized foods or chews of animal origin.
3. Ensure that the patient practices hand hygiene before and
after presenting the treat to the animal.
4. Instruct the patient to present the treat with a flattened palm.
VI. Contact tracing
A. The facility should develop a system of contact tracing that
at a minimum requires animal handlers to sign in when
visiting and ideally provides a permanent record of areas
and/or room numbers where the animal has interacted
with patients.
VII. Environmental cleaning
A. Practice routine cleaning and disinfection of environmen-
tal surfaces after visits. Clean and disinfect all areas (eg,
floors, chairs) with an EPA-registered hospital disinfectant.
B. It is recommended that clean additional bed sheet be used
to cover the bed if the animal has contact with surface of the
bed, and this should be removed and laundered after the
animal visit. If a separate sheet is not used, replace any
bedding that might be contaminated.
service animals
Background
The Americans with Disabilities Act (ADA) is a US Federal law
that was passed in 1990 and has been subsequently updated.
9
This law established certain legal rights for persons with service
animals and defined the minimum access required by law.
Under the ADA, “service animals”are defined as “dogs that are
individually trained to do work or perform tasks for people
with disabilities.”
9
The ADA provides a limited exception for
miniature horses if these animals otherwise satisfy the defini-
tion of a “service animal,”are housebroken, and do not create
safety concerns. Legal protection extends only to individuals
who are disabled, as defined under the ADA, not all patients
with medical or psychological conditions. While a full
exploration of what constitutes a “disability”is beyond the
scope of this review, disability is generally defined by the
shea expert guidance: animals in healthcare facilities 13

statute as (1) a physical or mental impairment that sub-
stantially limits one or more major life activities, (2) a record
of such an impairment, or (3) being regarded as having such an
impairment.
Guidance provided by the Department of Justice makes
clear that service animals under the ADA are “working ani-
mals”and not pets, and they are trained to perform specific
duties or tasks. If the individual has a “disability”as defined by
the statute, service animals may include “alert”animals (ie, an
animal trained to alert a person about to have a seizure and to
take actions to protect that individual during the seizure) and
animals trained to assist individuals with post-traumatic dis-
tress syndrome (eg, calming that person during an anxiety
attack); however, a dog whose sole function is comfort or
emotional support is not considered a service dog. For more
information, see the guidelines provided by the Civil Rights
Division of the US Department of Justice.
18
Federal guidelines
limit the inquiries that staff may make when it is not obvious
that the person is disabled and is using a service dog, as defined
by the ADA. Staff may not require documentation about the
person’s disability or the animal’s training but may ask: (1) “Is
the dog a service animal required because of a disability?”
and (2) “What work or task is the dog trained to perform?”
While restriction of access to service animals is permitted
in situations where public health may be compromised, allergies
or fear of dogs by staff or other patients generally are not
acceptable reasons for denying access. The facility is required to
make adjustments as needed to accommodate the animal.
Guidance
I. Each healthcare facility should have a policy regarding the
admittance of service animals into the facility.
A. The policy allowing service animals into the facility should
be compliant with the Federal Americans with Disabilities
Act (ADA), any other applicable state and local regulations
(note that federal law pre-empts more restrictive state or
local regulations).
9,18
B. A policy regarding the entrance of service animals into the
facility should include the following information:
1. A clear definition of “Service Animals”that should be
consistent with the ADA (see Background of Section III for
definitions). The facility is not required to permit animals
in training to become service animals to enter the facility,
but may choose to do so, reserving the right to exclude such
animals at its discretion.
2. A statement that only dogs and miniature horses are
recognized as Service Animals under federal law.
3. A statement that service animals are NOT pets and should
NOT be approached, bothered, or petted.
4. A statement that the care of the service animal is the
responsibility of the patient or his or her designated visitor
(ie, it is not the responsibility of the healthcare facility’s
personnel). If the patient is unable to arrange for the care of
the service animal while in the facility, the animal should
not be permitted to remain.
5. Notification of the IPC that an inpatient has a service
animal, followed by discussion with the patient to make
sure the service animal complies with institutional policies.
6. A requirement that service animals be housebroken.
II. Persons with disabilities may be requested but not required
to have their service animal wear an identification tag (eg,
collar, tag, etc.) that identifies them as a service animal to
aid HCP in distinguishing service animals from pets.
III. Situations sometimes arise in which a patient or visitor
claims that a dog is a service animal (and the animal may
be wearing a vest or other item identifying it as a service
animal), but the animal’s behavior suggests that the
animals is not a service animal (eg, the animal appears
undisciplined, repeatedly approaches other visitors or
patients for attention, does not display any behavior that is
assisting its master, etc.). Healthcare providers or staff
may ask the patient to describe what work/tasks the
dog performs for the patient, but may not ask for a
“certification”or “papers.”There are no formal certifica-
tion or registration programs for service animals and
certificates and paperwork can be readily purchased for
any pet from various ‘agencies.’The facility’s policy
should note that the term “Service Animal,”as defined
under the ADA, does not include dogs used for the
provision of emotional support, well-being, comfort, or
companionship. It may be helpful to quote directly from
the ADA regulations that make this distinction.
IV. Situations in which a service animal may be excluded from
the healthcare facility include the following:
A. The animal exhibits aggressive behavior such as snarling,
biting, scratching, or teeth baring.
B. The animal is excessively noisy (eg, howling, crying, or
whining).
C. The animal is unable to properly contain bodily excretions
(eg, the animal is not housebroken, or has vomiting or
diarrhea).
D. If the facility’s personnel reasonably believes that a service
animal is infectious or ill (see animal-assisted activities
section III.H.1.b and c for examples), the animal should
not be allowed to remain with the person with a disability
until the animal is evaluated by a veterinarian and he/she
provides written certification, acceptable to the healthcare
facility, that the service animal does not pose an increased
risk to patients or staff.
E. The policy should include a list of locations from which
service animals are prohibited and reasons for that
exclusion.
1. Where exclusion is based solely on risk to the service
animal, the patient should be consulted.
2. When the service animal is restricted from accompanying
the patient, reasonable accommodation should be made
for the person with disability to function without the
14 infection control & hospital epidemiology

service animal. Areas from which service animals should be
prohibited include the following:
i. Invasive procedure areas where sterility is required, including
but not limited to the operating rooms, recovery rooms,
cardiac catheterization suites, and endoscopy suites.
ii. Patient units where a patient is immunocompromised or
deemed at particularly high risk for infection, or in isolation
for respiratory (droplet or airborne) contact, or compro-
mised host precautions, unless in a particular circumstance
a service animal does not pose a direct threat and the
presence of the service animal would not require a
fundamental alteration in the hospitals’policies, practices,
or procedures.
iii. Food and medication preparation areas where appropriate
hygiene is required, including but not limited to kitchen,
infant formula preparation room, and central and satellite
pharmacies.
iv. Areas where the service animal or equipment may be
harmed by exposure (eg, metal is not allowed in a magnetic
resonance imaging (MRI) room, and a dog may have metal
on a collar or in a surgical implant), after consultation with
the patient or his/her authorized representative. When
there is potential harm to the service animal (eg, animal
present in room during radiation therapy), the patient
should be advised of the potential harm and assumes full
responsibility for any harm to the service animal.
F. Legal counsel should be consulted prior to exclusion of a
service animal from a healthcare facility.
G. Any consideration of restricting or removing a service
animal should be done with careful discussion with the
patient (and/or his or her designee) to achieve consensus
and provide an understanding of the concerns.
V. The policy should include the following regarding the
health of the service animal:
A. The person with a disability (or his or her designee) is
responsible for ensuring the health and care of the service
animal.
B. Visiting or residing in a healthcare facility likely increases
the risk of the animal acquiring certain pathogens. The
healthcare facility assumes no liability for costs associated
with a hospital-associated infection in the service animal.
VI. The policy should address a service animal’s accompany-
ing a healthcare facility visitor to a patient room and
should include the following:
A. Persons with disabilities who are accompanied by service
animals are allowed to visit patients as long as visitation
occurs in accordance with the facility’s service animal
policy and the facility’s“visiting hours and regulations.”
B. Service animals are not allowed to visit other patients’
rooms, the dining rooms, or other public areas of the
facility unless accompanied by the person with a disability.
C. When a person with a disability visits a patient’s room, he
or she should check with the patient’s primary care nurse
before visiting to assure that no patient in the room has
allergies to the service animal or bears other significant
medical risks that would contraindicate being near an
animal. If another patient in the room has an allergy, other
significant medical risk from exposure to an animal, or is
fearful of the animal, other arrangements for visiting must
be made (eg, visit in day room or waiting room).
VII. The policy should address the following for a service
animals belonging to patients:
A. When patients with a service animal are assigned to a semi-
private room, the roommate must be screened for clinically
significant allergies to the service animal and, if such a
condition is present, either the patient with the disability or
the patient with animal allergies must be moved to another
room. Similarly, the patient or roommate must be moved if
the roommate is fearful or otherwise disturbed by the
presence of the animal.
B. IPC should be notified when patients are admitted with
service animals.
C. The patient must be able to make arrangements to have the
service animal fed, exercised, and toileted, without the
involvement of HCP.
VIII. The policy should specifically address the use of a
miniature horse trained to do work or perform tasks for
a person with a disability. Miniature horses generally
range in height between 24 inches and 34 inches
measured to the shoulders and generally weigh between
70 and 100 pounds. Factors used to assess whether a
miniature horse should be permitted in the healthcare
facility include the following:
A. Whether the miniature horse is housebroken.
B. Whether the miniature horse is under the owner’s control.
C. Whether the facility can accommodate the miniature
horse’s type, size, and weight.
D. Whether the miniature horse’s presence will not compro-
mise legitimate safety requirements necessary for safe
operation of the facility.
E. The policy should clearly state who is assigned to enforce
the policy (eg, legal).
research animals
Background
Health-science centers are dedicated to advancing human
health through basic as well as clinical and translational
research. Biomedical research often requires the application of
sophisticated equipment and clinical techniques for research
animals. Because of logistics and expense, some equipment
items and facilities may not be able to be dedicated solely for
animal use; thus, research animals may need to be studied in
human healthcare institutions using equipment and facilities
that are also used for humans. Similarly, on occasion, zoos or
veterinary facilities may appeal for use of human healthcare
facilities to diagnose or treat sick or injured animals. To
accommodate these situations, when applicable, acute care
shea expert guidance: animals in healthcare facilities 15

hospitals should have comprehensive policies and procedures
in place to ensure patient and public safety while enabling safe,
effective, and efficient evaluation and treatment of animals.
As healthcare facilities develop infection prevention policies
and procedures to evaluate and treat research animals, they
should focus on 2 factors: (1) animals can serve as a reservoir
and vehicle for potentially infectious pathogens, and (2) human
safety must take priority over research project goals. Our focus
is on transmission of infectious agents (see below); however, it
should be noted that some animal species may pose additional
threat, such as physical injury from large animals or
envenomation.
Potential pathogens can be transmitted from research
animals-to-humans. Accredited healthcare research centers
expend great effort to ensure research animal well-being and to
minimize the likelihood that research animals harbor human
pathogens. However, risk cannot be eliminated because many
potential pathogens are part of the normal microbiota of
animals. This brief guidance statement is not meant to catalog
all of the potential infectious agents that can be transmitted
from animals to humans. A few examples are noted below to
illustrate the range of pathogens and routes of inoculation.
1. Direct inoculation via percutaneous or mucosal membrane
exposure
A large number of pathogens can be carried in the blood
and body fluids of research and veterinary animals and have
on occasion been spread to laboratory workers or
healthcare providers. Examples include Streptobacillus
moniliformis (rat bite fever) resulting from the bite or
scratch of laboratory rodents;
19
herpes B virus encephalitis,
transmitted by the bite of non-human primates;
20
skin and
soft tissue infection due to Pasteurella multocida from cat
bites and scratches and dog bites;
21
and infection due to
lymphocytic choriomeningitis virus, associated with expo-
sures to laboratory rodents.
22
2. Inhalation
Coxiella burnetii (Q fever) and Chlamydophila psittaci
(psittacosis) are examples of pathogens that have been
spread from laboratory animals-to-humans.
23,24
3. Direct contact
Zoophilic dermatophytes (Microsporum canis,Trichophyton
mentagrophytes) may potentially be spread from infected
mammals to humans.
25
Similarly, MRSA has been noted to
colonize various domestic animal species.
4. Fecal–oral
A large number of pathogens may be carried subclinically in
the gastrointestinal tracts of laboratory animals and can
potentially be transmitted via the fecal–oral route. Examples
include Salmonella ssp. (many animal species), Campylobacter
ssp. (mammals, birds, reptiles) and Cryptosporidium ssp.
(mammals, reptiles, primates).
5. Indirect transmission via vectors
Occasionally, laboratory animals may harbor ectoparasites
(eg, fleas), and these may serve as vectors for transmission
of various pathogens to human laboratory personnel or
HCP.
To minimize the risk of transmission of pathogens to humans,
institutions should formulate thorough procedures to safely
conduct diagnostic and therapeutic procedures on research
animals and animals from veterinary or zoologic sources.
Guidance
I. Review and approval
A. Before any research animal is evaluated in a human
healthcare facility, the principal investigator should submit
a detailed protocol that is reviewed and approved by the
facility’s responsible individuals or committees including
the following:
1. IACUC
2. Radiation safety committee (if procedures utilize radiation
or radioisotopes), infection prevention and control depart-
ment, and the involved clinical departments (radiology,
surgical services, etc.).
B. External advice should be sought as necessary to ensure
that there is adequate expertise to identify risks and develop
preventive measures.
C. The review and approval process should be supervised and
monitored by a responsible entity, such as the institutional
Comparative Medicine Department or Infection Control
Department. In some circumstances, animals with active
or uncontrolled infections may need to be specifically
excluded from entering the facility (eg, open/draining
wounds, diarrheal illness).
1. In addition to approving proposed procedures involving
animals, the detailed protocol should address all relevant
issues, including the following:
a. When the procedure may be performed
b. Where the procedure is to be performed
c. What personnel will be involved
d. What personal protective equipment is required
e. What cleaning and disinfection practices will be required
f. What route(s) will be used to transport animals to and from
the clinical area
g. Who is responsible for transporting the animal to the
procedure area
h. Who is responsible for care and maintenance of the animal
II. Scheduling
A. After a protocol is approved, the investigator should work
with the appropriate clinical area to schedule procedures to
minimize the potential for animal contact with patients or
the public.
B. Procedures on animals should be scheduled after normal
clinical hours (ie, nights, weekends, and holidays) at a time
when facilities and equipment are not being utilized for
patient care.
16 infection control & hospital epidemiology

C. The researcher must remain sensitive to the vagaries of
clinical practice and must understand that clinical situations
may arise that preclude the use of facilities for research
animals even though the animal procedure had been
scheduled.
D. Effective communication between the researcher and the
clinical area manager is crucial.
III. Transportation
A. Animals must be transported to and from clinical areas in
an enclosed, escape-proof container that is opaque or
concealed. If the animal is too large for a carrier (eg, pigs),
it should be anesthetized prior to entry to the healthcare
facility, restrained, and covered by a blanket.
B. Transportation routes should be utilized that minimize the
potential for contact with patients or the public.
C. Service elevators should be used whenever possible.
D. Animals and patients or patient-care items should not be
transported on the same elevator.
IV. Procedures in patient care areas
A. Animals should be prepared prior to transport as indicated
for the procedure (eg, hair removal, skin preparation,
bladder catheterization, intravenous access).
B. Whenever possible, procedures should be done in the
housing area or otherwise away from human clinical areas.
C. All mobile equipment and materials not needed for the animal
procedure should be removed from the procedure room.
D. Consider covering the examination table with leak-proof
plastic sheeting that is lined with absorbent material.
E. Doors to the procedure room should be closed, and a “Do
Not Enter”sign should be posted.
F. Appropriate personal protective equipment should be
utilized by personnel.
V. Equipment
A. Use of disposable equipment is desirable.
B. When using equipment that is also used on patients, only
equipment that has an established protocol for proper and
effective cleaning and can be effectively disinfected or
sterilized (as appropriate) should be used.
C. Medical or surgical instruments, especially those invasive
instruments that are difficult to clean (eg, endoscopes) that
are used on animals should be reserved for future use only
on animals.
D. Only disposable or dedicated equipment should be used if
there is any chance such equipment may be contaminated
with prions (eg, bovine spongiform encephalopathy or
scrapie).
VI. Cleanup/waste disposal
A. At the conclusion of the procedure, the room must be
thoroughly cleaned with an EPA registered disinfectant that is
appropriate for the pathogen risks posed by the animals.
B. Patients are not allowed entry until the room has been
cleaned and disinfected.
C. If appropriate, a portable HEPA unit should be placed in
the room and run until the next work day to reduce
airborne particulate allergens.
D. All waste generated during the study should be considered
potentially biohazardous and be disposedas regulated waste.
VII. Veterinary procedures
A. Whenever possible, animals should be treated in facilities
specialized for animal care; however, the expense of specialized
equipment may preclude use solely for animals and, on
occasion, veterinary facilities or zoological institutions may
wish to utilize human healthcare equipment or facilities.
B. The practices and procedures noted above should be
employed to ensure human safety and animal well-being.
VIII. Zoo animals
A. Special care needs to be taken in the transport and care of
zoo animals that are venomous (eg, venomous snakes),
large (eg, elephant), or carnivorous (eg, tigers, lions).
B. Zoo animals must be accompanied by and contained at all
times by trained staff.
C. Contact of animals by HCP not affiliated with the research
or clinical activity should be prohibited.
personal pet visitation
Background
For the purposes of this document, ‘pet’refers to a ‘personal pet,’
namely a domestic animal that is owned by an individual patient
that is not a service animal nor an animal used for animal-assisted
activities. Visitation of patients by their own pets potentially
offers benefits and challenges. The stronger bond with the pet
could accentuate the positive impacts on the patient, and 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. Further, while visitation with pets can be
restricted, in theory, to only the individual patient, in practice,
this may not be the case, as pets could encounter various HCP,
visitors, and patients during their time in the facility. Therefore, it
cannot necessarily be assumed that the implications of visitation
of a personal pet are guaranteed to be restricted to an individual
patient. While petsare less scrutinized and would not necessarily
fulfill the requirements for animal-assisted activities visitation
programs, the potentially strong human-animal bond and
corresponding potential positive impact on the patient leads
many facilities to permit this activity.
Guidance
I. Each healthcare facility should have a policy regarding the
admittance of pet animals into the facility and an individual
that oversees the program.
II. Pets should, in general, be prohibited from entering the
healthcare facility, including pets of HCP, patients, and
visitors. Exceptions can be considered when the healthcare
team determines that visitation with a pet would be of
benefit to the patient and can be performed with limited
shea expert guidance: animals in healthcare facilities 17

risk to the patient, other patients, and healthcare facility as
a whole. The patient or guardian of the pet should be
informed of potential risks, which should be documented
in the chart. Situations where visitation with a pet might be
considered include the following:
A. Visitation of a terminally ill patient
B. Visitation of a patient who has been hospitalized for a
prolonged period of time
C. Visitation of a patient who has a close bond with the animal
and where the healthcare team suspects that visitation
could improve the patient’s physical or mental health
III. Visitation by a pet is different than animal-associated
activities or similarly structured activities. Risks from
visitation by patients’pets may be increased for the
following reasons:
A. There is no formal training of the owner/designee, as with
an animal-assisted activities handler(s).
B. Pets have not been temperament tested.
C. Pets do not typically undergo the same degree of health
assessment or exclusion practices (eg, age) as compared to
animals used in animal-assisted activities.
IV. The degree of restriction should take into consideration
the patient’s health and mental status, the patient’s
prognosis, and factors relating to the animal (eg, age).
V. Healthcare facilities that permit a single pet visitation to a
patient should have a written policy that includes the
following:
A. Approval should be obtained from IPC, as well as the
patient’s attending physician and nurse. Approval for the
visit should be included in the medical record, with details
about the animal, as well as the person responsible for the
animal’s transport and care.
B. Visitation should be restricted to dogs. Animals should be
at least 1 year of age and housebroken. Visitation by
younger animals could be considered on a case-by-case
basis considering the age of the animal, the species, and
potential benefits and risks to the patient.
C. Written information should be provided to the animal’s
owner/designee. This document must specify the following:
1. The approved date, time, and location of visitation.
2. The maximum duration of visitation of one hour.
3. Acceptable and unacceptable practices of the visiting
animal are similar to an animal-assisted activities visit.
4. Pre-visitation requirements of the owner/designee are
similar to an animal-assisted activities visit.
5. The owner or guardian of the animal is responsible to
supervise the animal at all times, prevent contact of other
individuals with the animal, promptly clean up any fecal or
urine accidents that occur, supervise the visitation process,
and report any events (eg, bite, scratch) to HCP.
D. In general, visitation should not be permitted in the
following situations:
1. Patients on contact or droplet isolation
2. Patients in an intensive care unit (ICU)
3. Patients whose cognitive status would result in an inability
to safely interact with the animal, unless it can be certain
that the patient will only be able to see, not touch, the
animal.
4. Visitation of patients that have undergone recent solid
organ or stem cell transplant or who are significantly
immunocompromised.
5. In some situations, these exclusions can be reconsidered by
IPC and clinical personnel based on the risk to the patient,
others in the healthcare facility or patient’s household, and
the anticipated benefits to the patient from pet visitation.
VI. An appropriate site for pet visitation should be selected
A. Visitation is best performed outside of the medical facility
whenever possible, consistent with facility rules for leaving
the facility under proper supervision.
B. If outdoor visitation is not possible, visitation should be
performed in a private room.
C. If visitation must occur in a multi-bed room, explicit per-
mission from the roommate (or roommate’s guardian) and
the roommate’s physician must be obtained prior to arrival
arriving.
D. Pets should not be fed, given treats, or provided with water
during visitation.
E. Animals should be taken directly to the site of visitation,
avoiding areas of heavy traffic.
F. The person transporting the animal should prevent the
animal from coming into contact with other patients
or HCP.
G. The pet should be transported in a carrier whenever
possible, or on a leash that is <2 m (6 ft) in length.
H. Animals must not be allowed to roam freely in the
visitation area.
I. A pet that is disruptive or exhibiting fearful or aggressive
behavior (eg, barking, snarling, biting) should be immedi-
ately removed. The program coordinator must be notified.
J. The pet should not have the ability to interfere with
medical measures (ie, not be able to damage IV tubing).
VII. The patient must perform hand hygiene immediately
before and after contact with the animal. It is recom-
mended that a clean additional bed sheet be used to cover
the bed if the animal has contact with surface of the bed,
and this should be removed and laundered after the
animal visit. If a separate sheet is not used, replace any
bedding that might be contaminated.
VIII. Pets of HCP should not be brought to a healthcare
facility unless part of a formal animal-assisted activities
program or for approved visitation of a patient who is a
family member.
other uses of ahc
Background
This guidance document has focused on the four major reasons
for animal use in healthcare facilities (ie, animal-assisted
18 infection control & hospital epidemiology

activities, service animals, animals for research, and pet
visitation); however, animals may occasionally be used in
healthcare facilities for other medical reasons, such as medic-
inal leeches and larva debridement therapy, educational
purposes (eg, zoo and farm animals), and decorative purposes
(eg, aquariums). These topics are briefly reviewed and guidance
recommendations provided.
Leeches
Leeches continue to be used in modern medicine in the
management of acute problems related to vascular congestion
in patients with reimplantation of digits and ears and in
reconstruction using cutaneous or muscle flaps.
26–30
The most
common leech used is Hirudo medicinalis. The use of medic-
inal leeches can increase the risk of wound infections. The
most common pathogen is Aeromonas hydrophila,
31–34
but
infection with Vibrio fluvialis has also been reported.
35
The
incidence of wound infection had been reported to be 20%.
36
Treatment of leeches with ciprofloxacin has been reported to
eliminate carriage of Aeromonas spp.
37
Systemic antibiotics
administered to patients have been found to penetrate into
leeches and to significantly reduce the rate of A. hydrophila
isolation compared with controls (ie, 12% vs 100%).
38
Unused leeches should be maintained by pharmacy. Used
engorged leaches should be consider capable of transmitting
bloodborne pathogens and should be disposed of as hazardous
waste.
Aquariums
A large number of bacterial infections may be acquired
by trauma sustained in water or by injuries caused by
water-dwelling animals.
39–41
The most important of these
pathogens are A. hydrophila, Edwardsiella tarda, Erysipelothrix
rhusiopathiae, Mycobacterium marinum, Vibrio cholerae non-
O1, Vibrio parahaemolyticus, and Vibrio vulnificus. Infections
with M. marinum can result from cleaning fish tanks.
42–51
One
study reported a public aquarium to be the source of an
outbreak of Legionnaires’disease.
52
Because fish tanks may harbor the aforementioned patho-
gens, fish tanks generally should be excluded from healthcare
facilities and both clinical and non-clinical areas; however,
aquariums may be permitted if maintained by trained per-
sonnel, use a closed system, and water pumps are designed to
prevent aerosalization.
Larvae
Myiasis is the condition wherein a live vertebrate host is
infested by fly larvae (maggots). Healthcare-associated myiasis
has been described as generally associated with warm weather,
open, unscreened windows, foul-smelling wounds, draining
body fluids, and depressed mental status.
53
In urban and
suburban regions of the United States, most cases of myiasis
are caused by the relatively benign facultative green blowfly. In
one prospective study, only 5% of the cases were hospital-
acquired. Researchers have reviewed the prevention and
management of nosocomial myiasis.
53,54
Larval debridement
therapy has been used around the world to promoted wound
healing.
55
Generally, larval debridement therapy has used the
disinfected fly larvae of Lucilia sericata in the treatment of
wounds resistant to conventional therapy.
56,57
However, large
controlled clinical trials assessing benefits and risks of this
therapy have not been performed.
Zoo Animals
Petting zoos and animal exhibits have been associated with
multiple outbreaks. For this reason, in general, farm and other
animals should be prohibited from healthcare facilities.
Guidance
I. If medicinal leeches are used, they should be purchased
from a medical supply vendor, maintained in pharmacy,
and discarded as regulated medical waste after used
(engorged).
a. Consider decolonizing leeches (ie, eliminate carriage of
Aeromonas) by feeding leeches on an appropriate anti-
biotic or prophylactically treating the patient with an
appropriate antibiotic.
II. Fish tanks in hospitals should not be allowed due to the
risks of infection from maintenance of the fish tank and
the possibility of aerosol transmission of Legionella spp.
If a facility chooses to have an aquarium, it should be
covered, not accessible to patients, maintained by a
professional staff, and not placed in a clinical area or in
an area with immunocompromised patients. Protocols
should be established for aquarium management, includ-
ing measures to reduce contamination of the environment
with aquarium water. Because of the increased risks
associated with reptiles (eg, aquatic turtles)
62
and amphi-
bians (eg, African dwarf frogs),
63
aquatic reptiles should not
be kept in aquariums in healthcare facilities.
III. If maggot debridement therapy is used, only appropriate
decolonized flies or fly larvae should be purchased.
Maggots should be handled as biohazardous waste after
being removed from a patient.
IV. Farm and zoo animals events should be not allowed in a
healthcare facility or on healthcare facility property (eg,
outside the facility).
areas for future research
As the role of AHC evolves, there is a need for research to
establish evidence-based guidelines for their management.
Carefully conducted randomized controlled trials are needed
to assess the benefits of animal-assisted activities in healthcare.
shea expert guidance: animals in healthcare fa cilities 19

Additionally, there is a need for the systematic evaluation of
risks of animals in healthcare based on the category of use
(eg, animal-assisted activities, service animal, research, and
personal pet visitation). Prospective tracking of adverse out-
comes associated with AHC facilities will help to refine and
clarify the approaches recommended in this guidance. In
addition, publication of any outbreaks, clusters or infections
attributable to the presence of AHC facilities should be
encouraged. Finally, prospective studies on optimal infection
prevention practices for management of animals in healthcare
are needed.
acknowledgments
The Association for Professionals in Infection Control and Epidemiology
(APIC) endorses this paper.
Financial support: This study was supported in part by the SHEA Research
Network.
Potential conflicts of interest: All authors have no conflicts to disclose that are
relevant to this work.
Address correspondence to David J. Weber, MD, MPH; 2163 Bioinfor-
matics, CB #7030, Chapel Hill, NC, 27599-7030 (dweber@unch.unc.edu).
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