Knowledge, Attitudes, and Practices Related to Pet Contact by Immunocompromised Children with Cancer and Immunocompetent Children with Diabetes Jason W. Stull, VMD, MPVM, PhD1,2, Jason Brophy, MD, MSc3, Jan M. Sargeant, DVM, PhD2,4, Andrew S. Peregrine, BVMS, PhD, DVM1,2, Margaret L. Lawson, MD, MSc3, Raveena Ramphal, MBChB, MPH3, Lindy Samson, MD3, Jennifer Bowes, MSc3, and J. Scott Weese, DVM, DVSc1,2 Objective To compare knowledge, attitudes, and risks related to pet contact in households with and without immunocompromised children.
Study design A questionnaire was distributed to parents of children diagnosed with cancer (immunocompromised; n = 80) or diabetes (immunocompetent; n = 251) receiving care at the Children’s Hospital of Eastern Ontario. Information was collected on knowledge of pets as sources of disease, concerns regarding pet-derived pathogens, and pet ownership practices. Data were analyzed with multivariable logistic regression. Results The questionnaire was completed by 65% (214 of 331) of the individuals to whom it was given. Pet ownership was common; 45% of respondents had a household pet when their child was diagnosed, and many (households with a child with diabetes, 49%; households with a child with cancer, 20%) acquired a new pet after diagnosis. Most households that obtained a new pet had acquired a pet considered high risk for infectious disease based on species/age (diabetes, 73%; cancer, 77%). Parents of children with cancer were more likely than parents of children with diabetes to recall being asked by a physician/staff member if they owned a pet (OR, 5.9) or to recall receiving zoonotic disease information (OR, 5.3), yet these interactions were reported uncommonly (diabetes, #13%; cancer, #48%). Greater knowledge of pet-associated pathogens was associated with recalled receipt of previous education on this topic (OR, 3.9). Pet exposure outside the home was reported frequently for children in non–pet-owning households (diabetes, 48%; cancer, 25%). Conclusion Improved zoonotic disease education is needed for pet-owning and non–pet-owning households with immunocompromised children, with ongoing provision of information while the children are at increased risk of disease. Additional efforts from pediatric and veterinary healthcare professionals are required. (J Pediatr 2014;165:348-55).
T
he psychological and physical benefits of pet ownership for children and immunocompromised individuals are well documented.1-4 However, despite the benefits, there are potential health hazards associated with pet ownership and contact. Pets can cause physical harm to people through bites and scratches, as well as by transmitting zoonoses (pathogens transmitted from animals to people).5 Health risks are particularly high for those with a compromised or incompletely developed immune system, who may be at increased risk for infection. In these populations, disease is more likely to be severe, and the diagnosis may be elusive owing to a slow serologic response or atypical presentation.5,6 For these reasons, prevention of zoonotic disease is especially important in immunocompromised individuals. Many of the disease risks associated with pet contact can be reduced through simple measures, such as hand hygiene, proper animal selection, and changes in animal contact. Successful infection prevention requires that individuals in contact with animals be aware of the disease risks. To date, few studies have evaluated the knowledge of and attitudes about pet-associated zoonoses for immunocompromised individuals,3,4,7 and no study has evaluated these topics specifically in parents of immunocompromised children. Cancer and its related therapies usually result in an immunocompromised From the Department of Pathobiology, Ontario state, which increases the risk of infectious diseases, including zoonoses.8 In Veterinary College, Center for Public Health and Zoonoses, University of Guelph, Guelph, Ontario, contrast, although diabetes mellitus in adults has been associated with an Canada; Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada; and Department of Population increased risk of infectious disease in some studies,9,10 children with diabetes Medicine, Ontario Veterinary College, University of have not been shown to have altered immunity or to be at increased risk for inGuelph, Guelph, Ontario, Canada 11,12 J.S. was supported through a Canadian Institutes of fectious disease. Health Research (CIHR) Institute of Population and Guidelines addressing pet-associated zoonoses for cancer patients have been Public Health/Public Health Agency of Canada Applied 13,14 Public Health Research Chair. J.W. was supported in extrapolated from existing documents and target personal hygiene and types part by a CIHR Canada Research Chair in Zoonotic Dis1
2
3
4
eases.The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc.
CHEO
Children’s Hospital of Eastern Ontario
All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.04.045
348
Vol. 165, No. 2 August 2014 and ages of animals best suited as pets.15-17 Yet research has not determined whether these guidelines are provided systematically to cancer patients, or to what extent they are recalled or followed. The objective of the present study was to characterize the knowledge, attitudes, and risks related to pet ownership and animal contact in households of children who are immunocompromised (ie, currently or recently receiving active cancer therapy) compared with households of children with chronic illness who are not immunocompromised (ie, those with diabetes mellitus).
Methods On days of enrollment, all parents or guardians of children receiving medical care through the oncology or diabetes clinics at the Children’s Hospital of Eastern Ontario (CHEO; Ottawa, Canada) were approached at the time of a regularly scheduled appointment and invited to participate in the study. Eligibility criteria included: (1) age between 1 and 18 years; (2) previous diagnosis of diabetes mellitus or a condition requiring hematopoietic stem cell transplantation, chemotherapy, or radiation therapy with current chemotherapy or radiation treatment or no more than 1 year since transplantation or initiation of radiation or chemotherapy treatment; and (3) at home for a minimum of 30 cumulative days since initiation of treatment for diabetes or cancer. There were no exclusion criteria. One parent or guardian for each eligible child was asked to complete a confidential 15-minute self-administered written questionnaire (materials available in English and French). A stamped envelope was provided to those unable to complete the questionnaire onsite. Parents of children with diabetes were chosen as the referent group because they have frequent contact with healthcare providers with anticipatory guidance recommended for multiple aspects of daily life but without additional precautions related to exposure to infectious diseases.18 The study was approved by the Research Ethics Boards of CHEO and the University of Guelph. No incentives were offered for participation in the study. At the time the study was conducted, no specific education on pet-associated disease risks was provided routinely by the clinicians/staff attending the diabetes clinic. Pet-related information was believed to be provided usually by the oncology staff at the time of diagnosis and was physiciandependent. Usual recommendations included that patients keep existing pets, with the exception of rodents and turtles, but to not acquire any new pets. This information usually was provided at the time of diagnosis as part of a more comprehensive education session covering numerous topics, with parents needing to absorb a large amount of information in a single session. Enrollment occurred between August 2011 and March 2012. A 6-page questionnaire (available on request from the authors) was developed with guidance from veterinarians, physicians, and zoonotic disease experts; pretested on 6 members of the public with varying zoonotic disease backgrounds; and revised accordingly. The final questionnaire
used closed-ended, primarily multiple choice or Likert-type scale questions. It gathered both individual and householdlevel data, including demographic information, pet ownership history, pet contact–related attitudes, knowledge of zoonotic diseases and sources of their information, recall of pet-associated disease recommendations provided by physicians and veterinarians, and recall of the occurrence of animal contact and pet-associated injuries and zoonotic diseases. The immigrant generation status of the respondent, a designation indicating whether they or their parents were born outside Canada, was included, because this was considered potentially associated with pet ownership behavior; status was assigned based on established criteria.19 High-risk pets were defined as those species for which data on pathogen carriage or zoonotic transmission has led to established guidelines recommending their exclusion or cautioning ownership in households with individuals at high risk for disease (ie, dogs/cats aged 7), based on the overall median value. The continuous variables “child’s age” and “time since child diagnosed” were categorized based on quartiles and biological relevance (age [years]:
Study design A questionnaire was distributed to parents of children diagnosed with cancer (immunocompromised; n = 80) or diabetes (immunocompetent; n = 251) receiving care at the Children’s Hospital of Eastern Ontario. Information was collected on knowledge of pets as sources of disease, concerns regarding pet-derived pathogens, and pet ownership practices. Data were analyzed with multivariable logistic regression. Results The questionnaire was completed by 65% (214 of 331) of the individuals to whom it was given. Pet ownership was common; 45% of respondents had a household pet when their child was diagnosed, and many (households with a child with diabetes, 49%; households with a child with cancer, 20%) acquired a new pet after diagnosis. Most households that obtained a new pet had acquired a pet considered high risk for infectious disease based on species/age (diabetes, 73%; cancer, 77%). Parents of children with cancer were more likely than parents of children with diabetes to recall being asked by a physician/staff member if they owned a pet (OR, 5.9) or to recall receiving zoonotic disease information (OR, 5.3), yet these interactions were reported uncommonly (diabetes, #13%; cancer, #48%). Greater knowledge of pet-associated pathogens was associated with recalled receipt of previous education on this topic (OR, 3.9). Pet exposure outside the home was reported frequently for children in non–pet-owning households (diabetes, 48%; cancer, 25%). Conclusion Improved zoonotic disease education is needed for pet-owning and non–pet-owning households with immunocompromised children, with ongoing provision of information while the children are at increased risk of disease. Additional efforts from pediatric and veterinary healthcare professionals are required. (J Pediatr 2014;165:348-55).
T
he psychological and physical benefits of pet ownership for children and immunocompromised individuals are well documented.1-4 However, despite the benefits, there are potential health hazards associated with pet ownership and contact. Pets can cause physical harm to people through bites and scratches, as well as by transmitting zoonoses (pathogens transmitted from animals to people).5 Health risks are particularly high for those with a compromised or incompletely developed immune system, who may be at increased risk for infection. In these populations, disease is more likely to be severe, and the diagnosis may be elusive owing to a slow serologic response or atypical presentation.5,6 For these reasons, prevention of zoonotic disease is especially important in immunocompromised individuals. Many of the disease risks associated with pet contact can be reduced through simple measures, such as hand hygiene, proper animal selection, and changes in animal contact. Successful infection prevention requires that individuals in contact with animals be aware of the disease risks. To date, few studies have evaluated the knowledge of and attitudes about pet-associated zoonoses for immunocompromised individuals,3,4,7 and no study has evaluated these topics specifically in parents of immunocompromised children. Cancer and its related therapies usually result in an immunocompromised From the Department of Pathobiology, Ontario state, which increases the risk of infectious diseases, including zoonoses.8 In Veterinary College, Center for Public Health and Zoonoses, University of Guelph, Guelph, Ontario, contrast, although diabetes mellitus in adults has been associated with an Canada; Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada; and Department of Population increased risk of infectious disease in some studies,9,10 children with diabetes Medicine, Ontario Veterinary College, University of have not been shown to have altered immunity or to be at increased risk for inGuelph, Guelph, Ontario, Canada 11,12 J.S. was supported through a Canadian Institutes of fectious disease. Health Research (CIHR) Institute of Population and Guidelines addressing pet-associated zoonoses for cancer patients have been Public Health/Public Health Agency of Canada Applied 13,14 Public Health Research Chair. J.W. was supported in extrapolated from existing documents and target personal hygiene and types part by a CIHR Canada Research Chair in Zoonotic Dis1
2
3
4
eases.The authors declare no conflicts of interest. 0022-3476/$ - see front matter. Copyright ª 2014 Elsevier Inc.
CHEO
Children’s Hospital of Eastern Ontario
All rights reserved. http://dx.doi.org/10.1016/j.jpeds.2014.04.045
348
Vol. 165, No. 2 August 2014 and ages of animals best suited as pets.15-17 Yet research has not determined whether these guidelines are provided systematically to cancer patients, or to what extent they are recalled or followed. The objective of the present study was to characterize the knowledge, attitudes, and risks related to pet ownership and animal contact in households of children who are immunocompromised (ie, currently or recently receiving active cancer therapy) compared with households of children with chronic illness who are not immunocompromised (ie, those with diabetes mellitus).
Methods On days of enrollment, all parents or guardians of children receiving medical care through the oncology or diabetes clinics at the Children’s Hospital of Eastern Ontario (CHEO; Ottawa, Canada) were approached at the time of a regularly scheduled appointment and invited to participate in the study. Eligibility criteria included: (1) age between 1 and 18 years; (2) previous diagnosis of diabetes mellitus or a condition requiring hematopoietic stem cell transplantation, chemotherapy, or radiation therapy with current chemotherapy or radiation treatment or no more than 1 year since transplantation or initiation of radiation or chemotherapy treatment; and (3) at home for a minimum of 30 cumulative days since initiation of treatment for diabetes or cancer. There were no exclusion criteria. One parent or guardian for each eligible child was asked to complete a confidential 15-minute self-administered written questionnaire (materials available in English and French). A stamped envelope was provided to those unable to complete the questionnaire onsite. Parents of children with diabetes were chosen as the referent group because they have frequent contact with healthcare providers with anticipatory guidance recommended for multiple aspects of daily life but without additional precautions related to exposure to infectious diseases.18 The study was approved by the Research Ethics Boards of CHEO and the University of Guelph. No incentives were offered for participation in the study. At the time the study was conducted, no specific education on pet-associated disease risks was provided routinely by the clinicians/staff attending the diabetes clinic. Pet-related information was believed to be provided usually by the oncology staff at the time of diagnosis and was physiciandependent. Usual recommendations included that patients keep existing pets, with the exception of rodents and turtles, but to not acquire any new pets. This information usually was provided at the time of diagnosis as part of a more comprehensive education session covering numerous topics, with parents needing to absorb a large amount of information in a single session. Enrollment occurred between August 2011 and March 2012. A 6-page questionnaire (available on request from the authors) was developed with guidance from veterinarians, physicians, and zoonotic disease experts; pretested on 6 members of the public with varying zoonotic disease backgrounds; and revised accordingly. The final questionnaire
used closed-ended, primarily multiple choice or Likert-type scale questions. It gathered both individual and householdlevel data, including demographic information, pet ownership history, pet contact–related attitudes, knowledge of zoonotic diseases and sources of their information, recall of pet-associated disease recommendations provided by physicians and veterinarians, and recall of the occurrence of animal contact and pet-associated injuries and zoonotic diseases. The immigrant generation status of the respondent, a designation indicating whether they or their parents were born outside Canada, was included, because this was considered potentially associated with pet ownership behavior; status was assigned based on established criteria.19 High-risk pets were defined as those species for which data on pathogen carriage or zoonotic transmission has led to established guidelines recommending their exclusion or cautioning ownership in households with individuals at high risk for disease (ie, dogs/cats aged 7), based on the overall median value. The continuous variables “child’s age” and “time since child diagnosed” were categorized based on quartiles and biological relevance (age [years]:
