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Rabies in S.C.

For Healthcare Providers: DHEC Guide to Managing Animal Exposures and Rabies Postexposure Prophylaxis

Contents

Reporting Animal Exposures

Mandatory Reporting of Animal Bites
State Code of Laws Section 47-5-90. Reports of Animal Bites to Health Department
Every physician after his first professional attendance upon a person bitten by a pet or other animal, shall report the bite to the county health department and include the name, age, sex, weight, address, and telephone number of the person bitten. If no physician attends to the bite, it is the responsibility of the bitten adult or the parent or guardian of a bitten minor child to report the bite by the end of the next working day to the county health department.

Per the SC List of Reportable Conditions, animal (mammal bites are urgently reportable to SC DHEC.  Reports are to be made by phone within 24 hours of a provider’s attendance on the patient, or of receiving a report of a bite from a patient.

Providers are urged to report animal exposures to DHEC promptly to initiate the animal investigation. Most animal exposures will not require post-exposure prophylaxis (PEP); locating the animal for quarantine or testing may prevent unnecessary PEP. See county health department phone numbers.

DHEC Medical Consultation to Help You Make Post-exposure Prophylaxis Decisions

Medical Consultation is available regarding PEP and other animal bite/exposure management decisions.  Contact the DHEC medical consultant in your area to assist in determining if PEP is indicated using the following criteria:

  • Availability of the animal for observation or rabies testing
  • The type of exposure and the severity and location of the wound. For example, head and neck exposures are more urgent for evaluating the need for PEP
  • The epidemiology of animal rabies in the area of contact and the animal species involved
  • The circumstances of the exposure incident and whether abnormal animal behavior was noted for these circumstances.
  • A risk assessment weighing potential adverse consequences associated with PEP versus the actual risk for the person acquiring rabies.

Administration of rabies PEP is a medical urgency, not a medical emergency. The Advisory Committee on Immunization Practices advises clinicians to seek assistance from public health officials for evaluating exposures or determining the need for PEP. Public health officials have expertise in the evaluation of potential rabies exposures; and, and public health consultation is known to reduce unnecessary rabies PEP. DHEC physicians will continue to provide medical consultations.

Non-Bite Exposures

Non-bite exposures usually consist of scratches, or other open wounds on the victims’ bodies. A scratch or other open wound - alone - is not a valid rabies exposure, and therefore does not require rabies PEP.  In order to constitute a valid rabies exposure, either saliva or neural tissues from a rabid animal must be introduced into these open wounds. If saliva and/or neural tissues from known or suspect rabid animals are immediately introduced into open wounds, then the victim should receive rabies PEP.

The rabies virus is very rapidly desiccated, and thus inactivated, by either the ultraviolet radiation present in sunlight or heat. Once saliva from a rabid animal has left the animal’s mouth, the rabies virus in the saliva is considered to be inactivated as soon as the material is dry. Thus, saliva from rabid animals must be introduced into open wounds within a very short time frame, in order for the rabies virus to be viable, and thus constitute a valid rabies exposure.

Two other rare forms of non-bite exposures have been documented to cause rabies in human victims in the past. Corneal or other organ transplants from individuals infected with the rabies virus have transmitted rabies to the recipients of these tissue transplants.  Additionally, aerosol transmission of rabies has been known to have occurred in 2 laboratorians, as well as hypothesized in the case of 2 spelunkers, who were exposed to the rabies virus in South Western U.S. caves, which were filled with the guano of millions of bats.

On-line Rabies PEP Continuing Education Course for Providers

The Centers for Disease Control and Prevention (CDC) and the Maryland Department of Health and Mental Hygiene have developed an on-line continuing education (CE) course on rabies PEP for healthcare providers, epidemiologists, and veterinarians. This CE course, “Rabies Post-exposure Prophylaxis (PEP) Basics: Case Illustrations of the 2010 Advisory Committee on Immunization Practices (ACIP) Guidelines”, conveys 1 CE credit hour to the participant upon successful completion. The rabies PEP CE course is accessible at http://ideha.dhmh.maryland.gov/training/rabies/Default.aspx

Revised 4-Dose Rabies Vaccine Schedule

From March 19, 2010 MMWR:

Note to Readers:  In March, 2010, the Advisory Committee on Immunization Practices (ACIP) published recommendations to reduce the number of vaccine doses in the human rabies post-exposure prophylaxis (PEP) series from 5 to 4. This recommendation is based upon studies indicating 4 vaccine doses in combination with rabies immune globulin (RIG) elicited adequate immune response and a fifth dose did not contribute to more favorable outcomes. The number of doses recommended for persons with altered immunocompetence is unchanged; for such persons PEP should continue to comprise a 5-dose vaccination regimen with 1 dose of RIG.

For more information on the rationale behind this reduced schedule, read: Centers for Disease Control and Prevention.  Use of a Reduced (4-Dose) Vaccine Schedule for Post-exposure Prophylaxis to Prevent Human Rabies.  Recommendations of the Advisory Committee on Immunization Practices. MMWR 2010:59(No. RR-2), available at: http://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf

Evaluating Animal Exposures to Guide PEP Decisions

The following table, adapted from the Centers for Disease Control and Prevention’s Human Rabies Prevention1, offers guidance in evaluating the circumstances of animal exposures and indications for post-exposure prophylaxis.

Dogs, cats, and ferrets

  • Healthy and available for 10 days observation: Persons should not begin prophylaxis unless animal develops clinical signs of rabies.*
  • Rabid or suspected rabid – immediately begin prophylaxis.
  • Unknown (e.g., escaped) – Consult public health officials.

Skunks, raccoons, foxes, and most other carnivores; bats†

  • Regarded as rabid unless animal proven negative by laboratory tests§
    Consider Immediate prophylaxis.

Livestock, small rodents (rabbits and hares), large rodents (woodchucks and beavers), and other mammals

  • Consider individually
    Consult public health officials. Bites from squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, other small rodents, rabbits, and hares almost never require antirabies post-exposure prophylaxis.

*During the 10-day observation period, begin post-exposure prophylaxis at the first sign of rabies in a dog, cat, or ferret that has bitten someone. If the animal exhibits clinical signs of rabies, it should be euthanized immediately and tested.

†Post-exposure prophylaxis should be initiated as soon as possible following exposure to such wildlife unless the animal is available for testing and public health authorities are facilitating expeditious laboratory testing or it is already known that brain material from the animal has tested negative. Other factors that strongly influence the urgency of decision-making regarding initiation of post-exposure prophylaxis before diagnostic results are known include the species of the animal, the general appearance and behavior of the animal, whether the encounter was provoked by the presence of a human, and the severity and location of bites. Discontinue vaccine if appropriate laboratory diagnostic test (i.e., the direct fluorescent antibody test) is negative.

§The animal should be euthanized and tested as soon as possible. Holding for observation is not recommended.

1Centers for Disease Control and Prevention. Human Rabies Prevention – United States, 2008. Recommendations of the Advisory Committee on Immunization Practices. MMWR 2008;57(No. RR-3): pg 12.

Contacts for DHEC Consultation

During working hours animal bite reports are managed by the DHEC Environmental Health Offices and medical consultations are handled by the DHEC medical consultants. After working hours the DHEC on-call staff respond. To assure a prompt response to health care providers’ needs, the contact numbers for the Environmental Health Offices and the Medical Consultants are provided below for each county during regular working hours and after hours. Please call for assistance in the county of occurrence.

ANIMAL BITE REPORTS / MEDICAL CONSULTATION

Contact numbers for the Environmental Health Offices and Medical Consultants are provided below for each county during regular working hours. After hours, medical consultation is available as noted in the table.

 

During Working Hours

Nights/Weekends/ Holidays

County of Occurrence

Animal Bite Reports

Medical Consultation for Rabies PEP

All calls (Bite Reports and Medical Consultation)

Phone

Fax

Phone**
ABBEVILLE 864-366-2131 864-366-4105 888-218-5475

1-888-847-0902
AIKEN 803-642-1637 803-643-4027 803-642-1618
ALLENDALE 803-584-3818 803-584-8107 803-642-1618
ANDERSON 864-260-5585 864-222-3923 864-260-4358
BAMBERG 803-245-5176 803-245-5371 803-533-7199
BARNWELL 803-541-1061 803-541-1192 803-642-1618
BEAUFORT 843-525-7627 843-525-6730 843-605-3407
BERKELEY 843-719-4649 843-719-4321 843-953-0047
CALHOUN 803-874-2037 803-874-4693 803-533-7199
CHARLESTON 843-202-7020 843-202-7050 843-953-0047
CHEROKEE 864-487-2705 864-487-2728 864-596-2227 x210
CHESTER 803-385-6152 803-581-3815 803-286-9948
CHESTERFIELD 843-623-2117 843-623-3066 843-661-4830
CLARENDON 803-435-2592 803-435-6825 843-661-4830
COLLETON 843-549-2373 843-542-2814 843-605-3407
DARLINGTON 843-398-4401 843-398-4418 843-661-4830
DILLON 843-774-0648 843-774-2823 843-661-4830
DORCHESTER 843-821-9524 843-832-0765 843-953-0047
EDGEFIELD 803-637-4035 803-637-4039 888-218-5475
FAIRFIELD 803-635-6481 803-635-1410 803-576-2749
FLORENCE 843-661-4728 843-317-4044 843-661-4830
GEORGETOWN 843-915-8801 843-365-0099 843-915-8804
GREENVILLE 864-282-4146 864-282-4371 864-282-4139
GREENWOOD 864-227-5915 864-942-3680 888-218-5475
HAMPTON 803-943-3878 803-943-1067 843-605-3407
HORRY 843-915-8801 843-365-0099 843-915-8804
JASPER 843-726-7792 843-726-5320 843-605-3407
KERSHAW 803-425-6051 803-424-1611 843-661-4830
LANCASTER 803-285-6901 803-286-5418 803-286-9948
LAURENS 864-833-0000 864-833-6400 888-218-5475
LEE 803-484-6612 803-484-6314 843-661-4830
LEXINGTON 803-785-8113 803-785-8211 803-576-2749
MARION 843-423-8277 843-423-7179 843-661-4830
MARLBORO 843-479-6801 843-479-9658 843-661-4830
MCCORMICK 866-915-3024 864-942-3680 888-218-5475
NEWBERRY 803-321-2175 803-321-2300 803-576-2749
OCONEE 864-638-4185 864-638-4186 864-260-4358
ORANGEBURG 803-536-9105 803-533-7113 803-533-7199
PICKENS 864-898-5832 864-898-5858 864-282-4139
RICHLAND 803-576-2910 803-576-2935 803-576-2749
SALUDA 864-445-2141 864-445-7668 888-218-5475
SPARTANBURG 864-596-3415 864-596-3920 864-596-2227 x210
SUMTER 803-773-5511 803-773-6366 843-661-4830
UNION 864-429-1690 864-429-1697 864-596-2227 x210
WILLIAMSBURG 843-355-9378 846-355-9474 843-915-8804
YORK 803-909-7379 803-909-7538 803-286-9948

**If no response is received from county medical consultation number during working hours, call the Division of Acute Disease Epidemiology: 803-898-0861 (8:30 – 5:00, M-F)

 

Rabies Post-exposure Prophylaxis (PEP) Administration Schedule*


Not previously vaccinated

  • Wound cleansing
    All post-exposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.
  • Human rabies immune globulin (HRIG)
    Administer 20 IU/kg body weight. If anatomically feasible, the full dose should be infiltrated around and into the wound(s), and any remaining volume should be administered intramuscularly (IM) at an anatomical site distant from vaccine administration. Also, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, no more than the recommended dose should be given.
  • Vaccine
    Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area§), one each on days 0¶, 3, 7, and 14.**

Previously vaccinated†

  • Wound cleansing
    All post-exposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.
  • Human rabies immune globulin (HRIG)
    HRIG should not be administered.
  • Vaccine
    HDCD or PCECV 1.0 mL, IM (deltoid area §), one each on days 0 and 3.

*The regimens are applicable for all age groups, including children.

†Any person with a history of a complete pre-exposure or post-exposure vaccination regimen with HDCV, PCECV, or rabies vaccine adsorbed (RVA); prior PEP with HDCV, PCECV or RVA; or previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination.

§The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh can be used. Vaccine should never be administered in the gluteal area.

¶Day 0 is the day the first dose of vaccine is administered.

**For persons with immunosuppression, rabies PEP should be administered using all 5 doses of vaccine on days 0, 3, 7, 14, and 28.

If a patient does not receive the vaccine by the recommended schedule, consultation with a DHEC physician can assist in determining the appropriate schedule for completing the series and to determine whether titers are indicated to document an immune response. See “Serologic Testing by Rabies Fluorescent Focus Inhibition Test (RFFIT)”.

Rabies Post-Exposure Prophylaxis (PEP) Schedule and Administration Guidance For Persons Not Previously Immunized

Should any variation from the schedule occur, contact a DHEC Medical Consultant for additional guidance in completion of the series and assessment of antibody response.


Product

Route

Site

Dose

#Doses

Schedule

Human Rabies Immune Globulin 1

Infiltrate wound

Wound 2,Deltoid or quadriceps

20 IU/Kg (0.06 ml/lb)

1

Day 0 3

Rabies Vaccine 4

IM

Deltoid or anterolateral thigh for small children

1.0 ml

4*

Day 0, 3, 7, and 14*

1 HRIG is administered only once, at the beginning of prophylaxis, to previously unvaccinated persons. HRIG provides immediate protective antibodies until the patient mounts an active immune response to rabies vaccination.

2 As much of the product as is anatomically feasible should be infiltrated into and around the wound. Any remaining product should be administered intramuscularly in the deltoid or quadriceps (at a location other than that used for vaccine inoculation to minimize potential interference). The needle should be changed after wound infiltration and prior to IM injection.

3 If HRIG is not administered when vaccination is begun, it can be administered up to the seventh day after the first dose of vaccine. Beyond the seventh day, HRIG is not indicated because it can interfere with active antibody response to the vaccine administered on days 0–7.

4 Rabies vaccine is dispensed as five 1.0 ml kits

* For persons with immunosuppression, rabies PEP should be administered using all 5 doses of vaccine on days 0, 3, 7, 14, and 28.

For additional information or for Medical Consultation, contact your DHEC Region Medical Consultant, or the DHEC Division of Acute Disease Epidemiology by phone at (803) 898-0861 M-F 8:30 a.m. – 5:00 p.m. After working hours, call the statewide emergency answering service at (888) 847-0902 and ask for the DHEC doctor on call.

Manufacturers and Distributors of Rabies Biologics

DHEC will provide guidance to private providers in ordering rabies PEP biologics if needed. Establishing accounts with suppliers may simplify the acquisition process.

Human diploid cell vaccine

  • Imovax® Rabies
    Sanofi Pasteur
    Phone: 1-800-822-2463 (1-800-VACCINE)
    Website: http://www.vaccineshoppe.com
  • Contact Sanofi Pasteur at 1-800-VACCINE to place order.

Purified chick embryo cell vaccine

  • RabAvert®
    Norvartis Vaccines and Diagnostics
    Phone: 1-800-244-7668
    Website: https://www.novartisvaccinesdirect.com
    • ASD Healthcare – 1-800-746-6273
    • BDI Pharma – 1-800-948-9834. This national distributor is based in Columbia, For orders in the Columbia area call: 803-732-1018, www.bdipharma.com
    • Besse Medical – 1-800-543-2111
    • Cardinal – 1-800-964-5227
    • FFF Enterprises – 1-800-843-7477
    • General Injectables & Vaccines, Inc. (GIV) – 1-800-521-7468
    • Henry Schein, Inc – 1-800-772-4346
    • Insource, Inc – 1-800-366-3829
    • McKesson Medical-Surgical – 1-800-9509229

Rabies immune globulin

Patient Assistance Resources

Rabies vaccine manufacturers, Sanofi Pasteur and Novartis, have patient assistance programs for those who meet certain income eligibility criteria. Sanofi Pasteur’s Patient Assistance Program is administered by the Franklin Group; the comparable Novartis program is administered by RX for Hope. For information about patient assistance programs and application forms, please see the following contact numbers and links:

Serologic Testing by Rabies Fluorescent Focus Inhibition Test (RFFIT)

Every attempt should be made to adhere to the recommended vaccination schedules. Once vaccination is initiated, delays of a few days for individual doses are unimportant, but the effect of longer lapses of weeks or more is unknown. For most minor deviations from the schedule, vaccination can be resumed as though the patient were on schedule. When substantial deviations from the schedule occur, immune status should be assessed by performing serologic testing 7 – 14 days after administration of the final dose in the series.

It is recommended that the immunologic response be assessed using the Rabies Antibody Testing Rapid Fluorescent Focus Inhibition Test (RFFIT). When titers are obtained, specimens collected should completely neutralize challenge virus at a 1:5 serum dilution by the RFFIT. In the event that the patient does not demonstrate an adequate antibody response, it is recommended that the individual be retreated with the five dose rabies vaccine series on the correct schedule. Additional Human Rabies Immune Globulin (HRIG) is not indicated.

DHEC does not provide RFFIT. The following laboratories perform RFFIT titer testing:

Rabies Vaccine Information Sheet for Patients

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For additional information, contact:  (803) 896-0655  Fax (803) 896-0645

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