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