HEALTH ADVISORY - Rabies

Appropriate Use of Rabies Postexposure Prophylaxis (rPEP) in Vermont 
Rabies in Vermont

HEALTH ADVISORY
DATE:  July 27, 2020
TO:    Vermont Health Care Providers and Health Care Facilities
FROM:  Mark Levine, MD, Health Commissioner 

Need help now? 

Call the Vermont USDA Rabies Hotline at 1-800-4-RABIES (1-800-472-2437).

 
Appropriate Use of Rabies Postexposure Prophylaxis (rPEP) in Vermont 

Background:
      As we enter the peak of summer, reports of animal bites and bat encounters are increasing. While rabies is a consideration in these circumstances, a thorough risk assessment should always be performed prior to administration of rabies postexposure prophylaxis (rPEP). Unnecessary administration of rPEP can strain hospital and patient resources, crowd emergency department waiting rooms, and expose otherwise healthy patients to a variety of communicable diseases. 


What does rabies look like in Vermont?

       Rabies is a deadly viral disease of the brain that infects mammals. In Vermont, rabies is most commonly found in wild animals such as raccoons, skunks, foxes, bats and woodchucks. Cats, dogs and livestock can also get rabies if they have not been vaccinated. So far in 2020, five animals – three raccoons and two cats – have tested positive for rabies across the state. The virus is spread through the bite of an infected animal. Non-bite exposures very rarely result in rabies. People cannot get rabies indirectly, such as petting or handling animals, or from contact with urine, blood or feces.

Symptoms - Rabies is a disease of the central nervous system. Rabid animals show a change in their normal behavior, but you cannot tell whether an animal has rabies simply by looking at it. Animals may show unusual aggression, extreme depression or bizarre behavior. In humans, early rabies symptoms include fever, headache and general weakness. As the disease progresses, symptoms may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation (increase in saliva), difficulty swallowing, and hydrophobia (fear of water). Death will usually occur within days of these symptoms.

       What is considered a rabies exposure?
The virus is primarily spread through the bite of an infected animal. It is also possible for transmission to occur when infected saliva or neurologic tissue contacts a mucous membrane or open wound, such as a scratch from the animal. These non-bite exposures very rarely result in rabies. 
People cannot get rabies indirectly, such as by petting or handling animals, or from contact with urine, blood, feces, or fomites (such as bowls, beds, or surfaces contacted by potentially rabid animals). 

       All animal bites must be reported to the local Town Health Officer or other town official by calling or faxing a completed Town Health Officer Animal Bite Report Form. Health care providers must report the administration of rPEP by faxing a completed Rabies Postexposure Prophylaxis Report Form to the Health Department’s Epidemiology Program at 802-951-4061 or securely e-mailing it to AHS.VDHEpiLabRabies@vermont.gov.

Requested Action:
1.    Administer rPEP when appropriate.
rPEP should be given to a patient only when:
•    A person is bitten by a wild or domestic animal and the animal is not available for observation or testing, particularly if the bite was unprovoked or the animal was acting strangely.
•    A bat is found in the same room as a child or a sleeping person, and they cannot definitively rule out that they were bitten or scratched by the bat and the bat is not available for testing.
•    A person is severely bitten on the head, neck, or face by a wild animal, even if the animal is available for testing. rPEP may be discontinued if the animal tests negative for rabies.

      Consider delaying rPEP when further diagnostic information will soon be available, based on clinical judgement.

       There is no strict timeframe in which rPEP must be started to be effective, but it must be administered before symptoms of rabies develop, which can occur weeks to months after rabies virus exposure. rPEP is more effective at preventing rabies if administration is not significantly delayed after possible rabies exposure. However, if the animal that caused the potential rabies exposure is available for observation (domestic animals only) or testing, rPEP should be delayed until test results are available (about 48 hours once the animal arrives at the Health Department Laboratory) or until the end of the 10-day observation period as enforced by a Town Health Officer. rPEP is not necessary if the animal tests negative for rabies or if the animal (for dogs, cats, and ferrets) remains alive 10 days after biting a human. Small mammals or rodents such as rabbits, mice, and chipmunks are not routinely tested for rabies, but in rare circumstances may be submitted for testing with prior approval from the Health Department. These animals are rarely infected with rabies and are not known to transmit rabies to humans.

2.    Properly administer rPEP based on current ACIP recommendations.
The following quick reference table was recreated from the ACIP Rabies Vaccine Recommendations. 
https://www.healthvermont.gov/disease-control/zoonotic-diseases/rabies

For more information about rabies or to consult about a possible rabies exposure, please call the Vermont USDA Rabies Hotline at 1-800-4-RABIES (1-800-472-2437) or 211, or visit www.healthvermont.gov/rabies. An epidemiologist can be reached after-hours at 1-802-863-7240.