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For Medical Providers - Rabies

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May 24, 2017

There has been an increase in rabies among domestic animals in Monterey County over the last several years.  On July 2, 2015, a cat owned by an individual who resides within the City of Monterey tested positive for a bat variant rabies.  In 2012, a dog from the North Monterey County area was infected with a skunk variant of rabies.  Prior to 2012, rabies had not been diagnosed in domestic animals in Monterey County for at least 30 years.

Rabies is enzootic in Monterey County, particularly among skunks and bats.  While the canine variant of rabies is not found in California, all domestic animals in Monterey County including dogs and cats are at risk of infection with skunk and bat variants of rabies.  At this time, the Health Department recommends health care providers in attendance of patients with animal bites: 

  1. Clean the wound with soap and water or a virucidal agent.
  2. Evaluate the risk of rabies virus exposure.  Assessment should be based on:
    1. Number, severity, and location of bites:
      1. Any bite, scratch, or other situation in which saliva or central nervous system (CNS) tissue from a potentially rabid animal entered (or could have entered) an open or fresh wound or came in contact with a mucous membrane by entering the eye, mouth, or nose constitutes a potential exposure. 
      2. Due to the high incidence of rabies in bats and often undetectable puncture wounds in the skin from bat bites, handling/touching a bat or finding a bat in a room with a sleeping person alone represents a presumed rabies exposure. 
      3. Bites to the face, head, neck or spine represent a more exigent risk for rabies than bites to the arms or legs.  Other higher risk bites include bites to highly innervated tissues in the hands and fingers, multiple bites that expand the number of potential sites of virus entry, or severe bites that expose large amounts of underlying tissue.
      4. Low risk species:  Most rodents (gophers, chipmunks, squirrels, rats, mice), rabbits, and other small mammals (e.g., shrews, moles) are considered extremely low risk species. Bites from these animals rarely merit anti-rabies treatment.  
      5. If anatomically feasible, the full dose of HRIG should be thoroughly infiltrated in the area around and into the wound.  Any remaining volume should be injected intramuscularly (IM) at a site distant from vaccine administration.  The gluteal area should not be used.
      6. Most previously unvaccinated individuals should also receive 4 doses of rabies vaccine. 
        1. The first dose counts as day 0 of the vaccine series.  Doses should be administered on days 0 (with HRIG), 3, 7 and 14.
        2. A 5-dose regimen should be used for immunocompromised individuals with vaccine administered on days 0, 3, 7, 14, and 28.
        3. Dosage is 1.0 mL IM per dose for all ages.
        4. Rabies vaccine should be administered IM in the deltoid for adults and children.  Use of anterolateral thigh for infants.
          1. The gluteal area should never be used for rabies vaccine infections because administration in this area can result in lower antibody titers.
          2. Doses of rabies vaccine administered in the gluteal site should not be counted as valid doses and should be repeated.
    2. Biting animal’s species:
      1. High risk species: Wildlife include skunks, bats, coyotes, foxes, opossum, mountain lions and other wild cats, and raccoons. 
      2. Medium risk species:  Domestic animals including pets (cats and dogs) and livestock.   Domestic animals may be exposed to rabies virus either by being bitten by a rabid wild animal or through predation/consumption, resulting in direct contact between oral mucous membranes and infected neural tissue.
        1. An animal’s prior history of rabies vaccination reduces but does not exclude the possibility of rabies virus infection.  Failure of rabies vaccine in pets is rare but can occur, particularly among young animals and those that have only received one dose of vaccine.
    3. Biting animal’s behavior and potential for contact with wildlife:
      1. Rabid animals often respond in an excessive, inappropriate, and aggressive manner but can display a range of neurologic manifestations including unresponsive stupor.  There may also be a loss of normal fear of humans or activity during a time of day the species is not normally active.  However, the absence of abnormal behavior should not be regarded as evidence the animal is free from rabies.
      2. Pets that are housed outdoors or allowed to roam freely have more opportunity to be exposed to rabid wildlife than those that are kept indoors exclusively.
    4. Disposition of the biting animal:
      1. In many cases, PEP may be deferred for a short time to collect additional information about the implicated animal.
      2. When the risk of rabies is high, the animal should be euthanized and tested for rabies in a public health laboratory, if the animal can be safely captured.
      3. When the risk of rabies from a bite incident is judged to be lower, quarantine can offer an alternative to euthanasia and testing.  In most rabid animals, rabies virus is shed in saliva only after onset of clinical symptoms.  Because a rabid dog or cat will predictably show symptoms within 10 days of death, suspicion of rabies infectiousness can be eliminated if the biting dog or cat remains healthy and alive 10 or more days after a bite incident. 
    5. Previously vaccinated individuals should receive 2 doses: one immediately (day 0) and one 3 days later (day 3). 
      1. HRIG is not recommended for previously vaccinated individuals.
    6. If a patient misses or is late for a dose by a few days, the patient should resume the series maintaining the recommended spacing between doses.  For example, if a patient misses day 3 and presents on day 5 (2 days late), the day 3 dose should be given that day, the day 7 dose on day 9, and the remaining dose on day 16.
    7. If there is significant deviation from the schedule, resume the series maintaining the recommended spacing between doses (as above).  Antibody titers should be assessed by rapid florescent focus inhibition test (RFFIT) on a serum sample collected 14-28 days after finishing PEP to ensure a 1:5 serum dilution.
    8. There are reports in the literature that indicate human diploid cell vaccine (HDCV, IMOVAX®) and purified chick embryo cell (PCEC, RabAvert®) vaccines can be interchanged.  If the original vaccine type is not available, continue vaccination with the vaccine that is available.
  3. When risk assessment warrants, provide appropriate rabies post-exposure prophylaxis (PEP) following Advisory Committee on Immunization Practices’ (ACIP) guidelines:
    1. Pregnancy and infancy are not contraindications to PEP.
    2. All previously unvaccinated adults and children should receive human rabies immune globulin (HRIG) with their 1st dose of rabies vaccine. 
      1. If HRIG is not given with the first dose of vaccine, it may be administered through the 7th day after the 1st dose of rabies vaccine.
      2. Dose is 20 IU/kg (0.133 mL/kg) of body weight for all ages. Sample patient doses are:
        • 75 kg (165.4 lb) adult: 75 kg x 20 IU/kg = 1500 IU, or one 10 mL vial.
        • 30 kg (66 lb) child: 30 kg x 20 IU/kg = 600 IU, or two 2 mL vials.
  4. Promptly report animal bites to Monterey County Animal Services (phone: 831-769-8850).  A blank reporting form is available at http://www.co.monterey.ca.us/government/departments-a-h/health/monterey-county-animal-services/get-help/animal-bites-rabies.   

If you have additional questions or concerns, please call the Monterey County Health Department’s Epidemiology & Surveillance Unit at 831-755-4698 or refer to the Centers for Disease Control and Prevention’s website: http://www.cdc.gov/rabies/, the ACIP’s recommendations for rabies prevention available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm, and the California Department of Public Health’s Investigation, Management, and Prevention of Animal Bites in California available at: https://archive.cdph.ca.gov/HealthInfo/discond/Documents/InvestigationManagementandPreventionofAnimalBitesinCA2014.pdf.  

Monterey County Health Department

Guidance for Evaluating Risk of Rabies Virus Exposure

Animal Species

Animal Quarantined by Animal Control?

Type of Bite

Consider PEP?

Dog, Cat, Ferret, or Livestock

 

Yes

Provoked*

No, unless the animal develops clinical signs of rabies in quarantine

Unprovoked

Yes, especially if the bite occurred above the shoulders and/or the animal appeared unhealthy; PEP can be discontinued if the animal is tested and found free of rabies

No

Provoked*

No, unless the bite occurred in a developing county

Unprovoked

Yes, especially if the animal appeared unhealthy

Bat, Skunk, Coyote, Raccoon, Opossum, Fox, or Other Carnivore

Yes or No

Provoked* or Unprovoked

Yes, consider immediate PEP; PEP can be discontinued if the animal is tested and found free of rabies

Small Rodents (e.g., squirrels, rats, hamsters, mice), or Lagomorphs (e.g., rabbits, hares)

Yes or No

Provoked* or Unprovoked

No, unless the animal appeared unhealthy

 

*An attack is considered to be “provoked” if an animal is in a situation such that an expected reaction, from a veterinary perspective, would be to bite or attack. This includes: invasion of the animal’s territory; attempting to pet or handle an unfamiliar animal; startling an animal; running or bicycling past an animal; assisting an injured animal; trying to capture an animal; removing food, water, or other objects in the animal’s possession; or acting in an aggressive manner toward an animal.


 Monterey County Health Department

Guidance for Administration of Human Rabies

Immune Globulin and Rabies Vaccine

 

Human Rabies Immune Globulin (HRIG)

 

Schedule: HRIG is administered to previously unvaccinated individuals only once at the beginning of anti-rabies prophylaxis. HRIG provides immediate antibodies until individuals can actively produce antibodies of their own after vaccination. If HRIG is not administered with the first dose of vaccine, it can be administered up to 7 days after the administration of the first dose of vaccine. Beyond the 7th day, HRIG is not recommended since an antibody response is likely to have occurred.

 

HRIG is not recommended for previously vaccinated individuals.

 

Dosage: The recommended dose of HRIG is 20 IU/kg for ALL ages. Because HRIG can partially suppress active production of antibody, no more than the recommended dose should be administered.

 

Routes and Sites of Administration: If anatomically feasible, the full dose of HRIG should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume should be injected intramuscularly (IM) at a site distant from vaccine administration. The gluteal muscle is an acceptable site for HRIG but not for rabies vaccine.

 

HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose. However, subsequent doses of vaccine in the 4-dose series can be administered in the same anatomic location where the HRIG dose was administered.

Rabies Vaccine

 

Schedule: The first dose counts as day 0 of the vaccine series. For previously unvaccinated individuals, doses should be administered on days 0, 3, 7, and 14.

 

Previously vaccinated individuals should receive two doses, one immediately (day 0) and one 3 days later (day3).

 

A 5-dose regimen should be used for immunocompromised individuals with vaccine administered on days 0, 3, 7, 14, and 28.

 

Dosage: The dosage is 1.0 ml IM per dose for ALL ages.

 

Routes and Sites of Administration: Rabies vaccine should be administered IM in the deltoid for adults and children. Use the anterolateral thigh for infants.

 

The gluteal area should never be used for rabies vaccine injections because administration in this area can result in lower antibody titers. Doses of rabies vaccine administered in the gluteal site should not be counted as valid doses and should be repeated.

 

Acceptable Rabies Vaccine Injection Sites

MCHD_RabiesInjectionSites