Navigating a Potential Rabies Exposure
NavigatingNavigating aa PotentialPotential RabiesRabies Exposure:Exposure: UsingUsing thethe ““ PinkPink ”” andand ““ GreenGreen ”” SheetsSheets
KimberlyKimberly Signs,Signs, DVMDVM ZoonoticZoonotic DiseaseDisease EpidemiologistEpidemiologist MichiganMichigan DepartmentDepartment ofof CommunityCommunity HealthHealth ObjectivesObjectives
Describe:Describe: MichiganMichigan LawsLaws andand referencereference documentsdocuments relatedrelated toto rabiesrabies ACIPACIP GuidelinesGuidelines forfor HumanHuman RabiesRabies PreventionPrevention MichiganMichigan EpidemiologyEpidemiology MichiganMichigan RabiesRabies ExposureExposure ProtocolsProtocols forfor peoplepeople bittenbitten byby animals,animals, andand mammalsmammals whichwhich havehave bittenbitten peoplepeople oror petspets ScenariosScenarios PublicPublic HealthHealth ImportanceImportance ofof RabiesRabies
RabiesRabies isis thethe infectiousinfectious diseasedisease withwith thethe highesthighest knownknown casecase fatalityfatality raterate RabiesRabies remainsremains anan importantimportant publicpublic healthhealth problemproblem iinn developingdeveloping countries,countries, withwith 50,00050,000 casescases estimatedestimated annuallyannually aroundaround thethe worldworld (99%(99% duedue toto dogdog --strainstrain rabies)rabies) DevelopedDeveloped countriescountries seesee indigenousindigenous oror importedimported casescases sporadicallysporadically TheThe annualannual costscosts ofof preventingpreventing rabiesrabies inin thethe U.S.U.S. aarere estimatedestimated toto bebe overover $300$300 millionmillion andand risingrising HumanHuman RabiesRabies inin thethe U.S.U.S.
CasesCases havehave decreaseddecreased dramaticallydramatically sincesince thethe earlyearly 2020 th centurycentury OfOf thethe 4747 casescases ofof humanhuman rabiesrabies reportedreported inin thethe U.S.U.S. betweenbetween 19901990 --2004,2004, 3737 (78.7%)(78.7%) werewere duedue toto rabiesrabies virusvirus variantsvariants indigenousindigenous toto thethe U.U. S.,S., andand 92%92% ofof thesethese werewere duedue toto batbat variantsvariants 20032003 -- TheThe firstfirst reportedreported humanhuman casecase ofof rabiesrabies inin thethe U.S.U.S. duedue toto thethe raccoonraccoon strainstrain (method(method ofof exposureexposure remainsremains unknown)unknown) 20042004 –– TheThe 11 st documenteddocumented survivorsurvivor ofof clinicalclinical rabiesrabies whowho diddid notnot receivereceive eithereither prepre -- oror postpost -- exposureexposure prophylaxisprophylaxis forfor rabiesrabies ImportantImportant ReferenceReference DocumentsDocuments StateState LawsLaws
PublicPublic HealthHealth Code,Code, CommunicableCommunicable DiseaseDisease RulesRules Michigan’sMichigan’s DogDog LawLaw OtherOther pertinentpertinent laws:laws: Ferrets Dangerous Animals Act Large Carnivore Act Wolf -dog Cross Act BODA (Bodies of Dead Animals Act) CommunicableCommunicable DiseaseDisease RulesRules (Promulgated(Promulgated underunder thethe AuthorityAuthority ofof Michigan’sMichigan’s PublicPublic HealthHealth Code)Code) “Animal“Animal bites,bites, wherewhere rabiesrabies isis considered,considered, shouldshould bebe reportedreported toto thethe locallocal healthhealth jurisdictionjurisdiction wherewhere thethe bitebite occurred,occurred, andand ifif different,different, thethe locallocal healthhealth jurisdictionjurisdiction wherewhere thethe patientpatient liveslives oror wherewhere thethe serviceservice facilityfacility isis located.located. TheThe reportreport mustmust bebe mademade withinwithin 2424 hourshours ofof thethe bitingbiting incident.incident. TheThe reportreport shallshall includeinclude allall ofof thethe followingfollowing information:information: CommunicableCommunicable DiseaseDisease RulesRules ((con’tcon’t ))
AnimalAnimal speciesspecies inflictinginflicting thethe bitebite AnimalAnimal owner’sowner’s name,name, address,address, andand telephonetelephone numbernumber VaccinationVaccination statusstatus ofof animalanimal DateDate andand locationlocation ofof bitingbiting incidentincident Name,Name, address,address, andand telephonetelephone numbernumber ofof thethe personperson bittenbitten SiteSite ofof thethe bitebite onon thethe bodybody NameName ofof thethe reporterreporter ofof bite”bite” Updated annually RabiesRabies CompendiumCompendium
GuidelinesGuidelines forfor preventionprevention andand controlcontrol ofof rabiesrabies inin animals.animals. Domestic animals Wildlife Zoos and exhibits Import and interstate movement Post -exposure management AnimalAnimal vaccinationvaccination recommendationsrecommendations ListList ofof licensedlicensed rabiesrabies biologicsbiologics forfor animalsanimals
ACIPACIP GuidelinesGuidelines
BiologicsBiologics PrePre --exposureexposure vaccinationvaccination PostPost --exposureexposure prophylaxisprophylaxis Types of exposure: bite, non -bite Epidemiology and evaluation of involved species Treatment of wounds Immunization TreatmentTreatment outsideoutside thethe U.S.U.S. SerologicSerologic testingtesting AdverseAdverse reactionsreactions PrecautionsPrecautions andand contraindicationscontraindications PrePre --exposureexposure VaccinationVaccination
HighHigh riskrisk groupsgroups VeterinariansVeterinarians AnimalAnimal handlershandlers CertainCertain laboratorylaboratory workersworkers PersonsPersons whosewhose activitiesactivities mightmight bringbring themthem intointo contactcontact withwith rabiesrabies virusvirus oror vectorvector speciesspecies InternationalInternational travelerstravelers Travel to areas where dog rabies is endemic Areas were access to biologics might be limited PrePre --exposureexposure SchedulesSchedules
SeriesSeries ofof threethree vaccinationsvaccinations Day 0, 7, and 21/28 BoosterBooster doses:doses: Continuous risk (rabies research or vaccine production facilities), titer check every 6 mos Frequent risk (rabies diagnostic testing, veterinarians and staff, animal control and wildlife officers in areas where rabies is endemic), titer check every 2 years WhereWhere cancan II getget rabiesrabies prepre --exposureexposure vaccinations?vaccinations? Clinics offering travelers immunizations, the cost is approximately $200/dose. EpidemiologyEpidemiology ofof RabiesRabies inin MichiganMichigan
Total: 41
MichiganMichigan RabiesRabies Cases,Cases, 20062006 EvaluationEvaluation ofof PotentialPotential ExposuresExposures “Pink“Pink Sheet”Sheet” RiskRisk AssessmentAssessment
SpeciesSpecies ofof animal?animal? WildWild RodentRodent Dog,Dog, cat,cat, ferretferret AnimalAnimal availableavailable forfor testing/observation?testing/observation? MichiganMichigan epidemiologyepidemiology forfor thatthat species?species? www.michigan.govwww.michigan.gov /rabies/rabies ObservedObserved healthhealth andand behaviorbehavior ofof thethe animal?animal? CircumstancesCircumstances ofof thethe bite?bite? TypeType ofof ExposureExposure Bite?Bite? SiteSite SeveritySeverity ImmediateImmediate cleansingcleansing NonNon --bite?bite? MucousMucous membranemembrane exposureexposure NonNon --intactintact skinskin BatBat inin roomroom withwith sleepingsleeping person,person, oror witnessedwitnessed inin roomroom withwith anan unattendedunattended child,child, mentallymentally disableddisabled oror intoxicatedintoxicated personperson ProvokedProvoked onon NonNon --provoked?provoked?
ExamplesExamples ofof provokedprovoked exposures:exposures: AttemptingAttempting toto feedfeed animalanimal EnteringEntering animalsanimals territoryterritory BreakingBreaking upup aa fightfight betweenbetween twotwo animalsanimals HandlingHandling anan injuredinjured oror wildwild animalanimal Walking,Walking, running,running, oror ridingriding aa bikebike pastpast anan animalanimal UnprovokedUnprovoked exposure:exposure: AnimalAnimal crossedcrossed neutralneutral territoryterritory toto initiateinitiate contactcontact GETGET DETAILS!!DETAILS!! SeveritySeverity andand SiteSite ofof BiteBite
HeadHead andand neck?neck? LengthLength ofof timetime toto receivereceive testtest resultsresults onon animal?animal? 24/724/7 testingtesting availableavailable forfor emergenciesemergencies MDCHMDCH BOLBOL cancan generallygenerally havehave resultsresults withinwithin 2424 --4848 hours,hours, andand inin mostmost cases,cases, PEPPEP cancan waitwait forfor resultsresults IfIf testingtesting isis delayed,delayed, PEPPEP maymay needneed toto bebe startedstarted AnimalAnimal TestsTests NegativeNegative
NoNo needneed toto initiateinitiate PEPPEP
PEPPEP cancan bebe discontinueddiscontinued ifif alreadyalready begunbegun “Grey”“Grey” areasareas
SituationsSituations thatthat dodo notnot fitfit intointo givengiven protocolsprotocols RequireRequire carefulcareful assessmentassessment ofof situationsituation “Worried“Worried well”well” MustMust assessassess thethe riskrisk ofof exposureexposure versesverses thethe potentialpotential riskrisk ofof treatmenttreatment SomeSome peoplepeople areare moremore riskrisk averseaverse thanthan othersothers WantWant toto avoidavoid unnecessaryunnecessary PEPPEP ifif possiblepossible WhatWhat WouldWould YouYou Do?Do?
PersonPerson bittenbitten byby aa straystray catcat thatthat ranran away.away. BatBat foundfound inin aa roomroom withwith aa sleepingsleeping pregnantpregnant woman.woman. BatBat waswas gentlygently collectedcollected andand releasedreleased safelysafely outout thethe backback door.door. NeighborsNeighbors unvaccinatedunvaccinated dogdog bitbit childchild inin thethe face.face. CuteCute orphanorphan babybaby skunkskunk waswas beingbeing bottlebottle fedfed byby aa family.family. ItIt becamebecame illill andand dieddied aboutabout 44 daysdays afterafter itit waswas found.found. ThisThis happenedhappened 22 weeksweeks ago.ago. FamilyFamily becamebecame worriedworried afterafter talkingtalking toto neighbors.neighbors. More…More…
BatBat foundfound deaddead inin kitchenkitchen sinksink withwith soakingsoaking babybaby bottles.bottles. BatBat teststests positivepositive forfor rabies.rabies. ChildChild bittenbitten byby anan africanafrican civetcivet ,, whichwhich isis partpart ofof aa travelingtraveling animalanimal exhibitexhibit thatthat visitsvisits schoolsschools toto educateeducate childrenchildren aboutabout thethe rainforest.rainforest. AdultAdult isis bittenbitten whenwhen tryingtrying toto pickpick upup aa squirrelsquirrel thatthat “looked“looked sick”.sick”. FamilyFamily justjust purchasedpurchased aa hamsterhamster fromfrom thethe locallocal petpet store,store, whichwhich bitbit theirtheir childchild whenwhen hehe pickedpicked itit up,up, thenthen waswas foundfound deaddead inin thethe cagecage thethe nextnext day.day. “Green“Green Sheet”Sheet” MammalsMammals WhichWhich HaveHave BittenBitten PeoplePeople WildWild Euthanize and test DomesticDomestic dogs,dogs, cats,cats, ferrets;ferrets; regardlessregardless ofof vaccinationvaccination statusstatus Healthy animal Confine 10 days If animal is unwanted, euthanize and test Ill animal Euthanize and test Stray animal Hold 4 days then euthanize and test Hold 10 days DomesticDomestic Livestock:Livestock: ConsultConsult MDA,MDA, MDCHMDCH ForFor PotentiallyPotentially ExposedExposed Dogs,Dogs, Cats,Cats, FerretsFerrets
RabiesRabies vaccinevaccine currentcurrent -- boosterbooster andand observeobserve 4545 daysdays RabiesRabies vaccinevaccine lapsed:lapsed: TestTest batbat oror wildwild animalanimal Negative - VACCINATE Positive - Euthanize, or vaccinate and confine for 6 months (or confine 6 months and vaccinate at 5 mos into confinement) WildWild animalsanimals unavailableunavailable --samesame optionsoptions asas forfor positivepositive wildwild animal,animal, dependingdepending onon assessedassessed riskrisk WhatWhat WouldWould YouYou Do?Do?
CatCat foundfound playingplaying withwith aa deaddead bat.bat. CatCat isis UTDUTD onon vaccines.vaccines. UnvaccinatedUnvaccinated dogdog inin fightfight withwith anotheranother dogdog whosewhose vaccinesvaccines areare notnot currentcurrent .. CatCat hashas suddensudden behaviorbehavior changechange andand bitesbites owner.owner. CatCat isis indoor/outdoorindoor/outdoor andand unvaccinated.unvaccinated. More…More…
DogDog withwith lapsedlapsed rabiesrabies vaccinevaccine tanglestangles withwith aa skunk,skunk, butbut thethe skunkskunk getsgets away.away. UnvaccinatedUnvaccinated catcat catchescatches batbat inin house,house, andand eatseats it.it. FamilyFamily findsfinds severalseveral batsbats deaddead onon property,property, hashas batsbats roostingroosting inin roofroof ofof barnbarn thatthat houseshouses unvaccinatedunvaccinated goats,goats, horses,horses, andand cats.cats. PostPost --ExposureExposure TreatmentTreatment forfor PreviouslyPreviously VaccinatedVaccinated
WhoWho isis previouslypreviously vaccinated?vaccinated? AA personperson whowho hashas receivedreceived eithereither recommendedrecommended prepre --exposureexposure oror postpost --exposureexposure regimensregimens withwith HDCV,HDCV, RVA,RVA, oror PCECPCEC AA personperson whowho hashas receivedreceived anotheranother regimen,regimen, andand hashas aa documenteddocumented rabiesrabies antibodyantibody titertiter
TwoTwo dosedose boosterbooster onon dayday 0,30,3 NoNo immuneimmune globulinglobulin neededneeded PostPost --ExposureExposure TreatmentTreatment ForFor NonNon --vaccinatedvaccinated PersonsPersons
RabiesRabies ImmuneImmune GlobulinGlobulin SeriesSeries ofof fivefive vaccinations,vaccinations, dayday 0,0, 3,3, 7,7, 14,14, andand 2828 ContactContact InformationInformation
MichiganMichigan DepartmentDepartment ofof CommunityCommunity Health:Health: 517517 --335335 --81658165
MichiganMichigan DepartmentDepartment ofof Agriculture:Agriculture: 517517 --373373 --10771077 ImportantImportant WebsitesWebsites
www.cdc.govwww.cdc.gov RabiesRabies sitesite
www.michigan.govwww.michigan.gov /rabies/rabies
www.nasphv.orgwww.nasphv.org “Publications”“Publications” Questions?Questions?