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Rabies in S.C.

DHEC Guide for Rabies Risk Assessment and
Postexposure Prophylaxis (PEP)


Contents

Rabies Overview

Rabies is an acute viral infection resulting in encephalomyelitis that is nearly always fatal.  The rabies virus proliferates in neural tissue and is found in high concentration in saliva following replication in the salivary glands.  The rabies virus may be transmitted by the introduction of saliva from a rabid mammal into a wound from a bite, or a scratch from contaminated claws.  Fresh saliva and neural tissue can also be infectious if introduced onto a mucous membranes or a fresh break in the skin.  The rabies virus does not circulate in blood or other body fluids.  Postexposure prophylaxis combining wound treatment, local infiltration of rabies immune globulin (RIG), and vaccination is uniformly effective when appropriately administered.

Reporting Animal Exposures

South Carolina State Law Mandates Reporting of Animal Bites
Animal (mammal) bites are a reportable condition in South Carolina.  As mandated by State Code of Laws Section 47-5-90.

Animal (mammal) bites are an urgently reportable condition under the SC List of Reportable Conditions.  Reports are to be made by phone within 24 hours of a provider’s attendance on the patient, or of the provider receiving a report of a bite from a patient.  See DHEC Contacts for Reporting or Medical Consultation. Reports of animal bites may also be faxed to DHEC using the DHEC form 1799.

Providers are required to report animal exposures to DHEC so that animal investigations can be promptly initiated. Most animal exposures do not require postexposure prophylaxis (PEP); locating the animal for quarantine or testing may prevent unnecessary PEP. 

DHEC Medical Consultants Assist with Rabies Risk Assessments

Administration of rabies PEP is a medical urgency, not a medical emergency. The Advisory Committee on Immunization Practices advises that clinicians seek assistance from public health officials when needed for evaluating the risk of rabies and determining if PEP is indicated given the circumstances of the exposure. Public health officials have expertise in the epidemiology of animal rabies and the indications for PEP and public health consultation is known to reduce unnecessary rabies PEP. DHEC physicians are available for medical consultations.  Refer to the DHEC Contacts for Reporting or Medical Consultation if you need assistance.

Evaluating Animal Exposures to Guide Postexposure Prophylaxis Decisions

Determining if PEP is indicated is based on a number of variables.  The following criteria should be taken under consideration:

  • Is the animal available for observation or rabies testing?
  • Did the exposure result in an observed wound like a bite or scratch, or was there mucous membrane exposure, or a potentially unrecognized wound from a bat?
  • The severity and location of the wound do not alone determine if PEP is indicated, but may dictate the urgency of treatment if needed.  For example, head and neck exposures require more urgent risk assessment.
  • The epidemiology of animal rabies, where the exposure occurred, and the animal species involved.
  • The circumstances of the exposure, including whether or not there was an unprovoked attack and whether the animal exhibited abnormal behavior.

Table 1: Rabies postexposure prophylaxis guide — United States, 2008 (adapted from Table 3 in the Centers for Disease Control and Prevention’s Human Rabies Prevention1, offers guidance in evaluating animal exposures and indications for postexposure prophylaxis)

Animal Type

Evaluation and disposition of animal

Postexposure prophylaxis recommendations

 

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 postexposure prophylaxis

1Centers for Disease Control and Prevention. Human Rabies Prevention – United States, 2008. Recommendations of the Advisory Committee on Immunization Practices.  http://www.cdc.gov/mmwr/PDF/rr/rr5703.pdf

*   During the 10-day observation period, begin postexposure 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.
†   Postexposure 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 the animal has already tested negative for rabies. Other factors that might influence the urgency of decision-making regarding initiation of postexposure 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.

 

Non-Bite Exposures

Rabies from non-bite exposures is rare; however non-bite exposures as a potential for rabies transmission require assessment.

PEP should be considered in the event of the introduction of fresh saliva and/or neural tissues from a known or suspected rabid animal into an open wound, fresh scratch or abrasion, or mucous membrane.  Exposure to blood, urine or other bodily fluids from a known or suspected rabid animal are not considered exposures.  Rabies virus is inactivated by desiccation, ultraviolet irradiation, and other factors like heat and sunlight and does not persist in the environment. In general, if the suspect material is dry, the virus can be considered noninfectious.

Bat Exposures

The majority of human rabies cases reported in the United States in the last few decades have been attributed to exposures to bats that were unrecognized as a risk for rabies transmission.  Bat bites cause minimal trauma making identification of a wound representing a potential exposure difficult.  A potential exposure to a bat requires a thorough evaluation if the bat is not available for testing.  If possible, bats involved in potential human exposures should be safely collected and submitted for rabies testing.  The majority of bats submitted for testing are not rabid.  Timely rabies testing will eliminate the need for risk assessments and unnecessary prophylaxis. 

PEP may be indicated if a potential bat exposure cannot be ruled out.  Examples include, a bat being found in the same room as a person who was deeply sleeping, or an adult witnesses a bat in the room with a previously unattended child, mentally disabled, or intoxicated person. If the person can be reasonably certain a bite, scratch, or mucous membrane exposure did not occur, or the bat tested negative for rabies, postexposure prophylaxis is not necessary. 

Online 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 online continuing education (CE) course on rabies PEP for healthcare providers, epidemiologists, and veterinarians. This CE course, “Rabies Postexposure 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://www.cdc.gov/rabies/resources/training/index.html or,
 http://ideha.dhmh.maryland.gov/training/rabies/Default.aspx.


Table 2.  Rabies Postexposure Prophylaxis (PEP) Schedule and Administration Guidance1

All PEP should begin with immediate and 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.

Vaccination status

Treatment2

Not previously vaccinated

Rabies PEP product

Dose

Route

Site

Schedule

Human Rabies Immune Globulin (HRIG)3

20 IU/kg  (0.06 ml/lb) body weight.  Do not administer HRIG in the same syringe as vaccine.  Give no more than the recommended dose to prevent suppression of the active immune response to the vaccine.

If anatomically feasible, the full dose should be infiltrated around and into the wound(s), and any remaining volume should be administered intramuscularly (IM) in the deltoid or quadriceps at an anatomical site distant from vaccine administration.  The needle should be changed after wound infiltration and prior to IM injection. 

Day 04

Vaccine5
Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV)

1.0 mL

IM

Deltoid area6

One each on days 0, 3, 7, and 14.7

Previously vaccinated8

Rabies PEP Product

Dose

Route

Site

Schedule

HRIG should not be administered

Vaccine5
Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV)

1.0 mL

IM

Deltoid area6

One each on days 0 and 3.4

1 Consultation with a DHEC Medical Consultant is recommended for any patient that does not receive the vaccine by the recommended postexposure prophylaxis schedule.  The DHEC Consultant can assist in determining the appropriate schedule for completing the series and in determining whether Rapid Fluorescent Focus Inhibition Test (RFFIT) titers are indicated to assess the adequacy of the immune response.

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

3 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. If HRIG is not administered when vaccination is begun, it can be administered up to the seventh day after the first dose of vaccine.  HRIG should not be given beyond the seventh day, to prevent interference with active antibody response to the vaccine.  HyperRAB (HRIG, by Talecris) and Imogam ® Rabies-HT (HRIG, by Sanofil Pasteur) are supplied in 2 mL and 10 mL single dose vials, with an average 150 IU per mL.  The 2 mL vial contains 300 IU and is sufficient for a child weighing 15 kg (33 pounds).  The 10 mL vial contains a total of 1500 IU, which is sufficient for an adult weighing 75 kg (165 pounds.)

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

5 Rabies Vaccine is dispensed as single dose 1.0 ml kits. 

6 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. 

7 In 2010, the Advisory Committee on Immunization Practices (ACIP) published recommendations to reduce the number of vaccine doses in the human rabies postexposure prophylaxis (PEP) series from 5 to 4.   MMWR 2010:59(No. RR-2), available at: http://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf.  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.  For persons with immunosuppression, rabies PEP should be administered using 5 doses of vaccine on days 0, 3, 7, 14, and 28.

8 Previously vaccinated is defined as any person with a history of a complete pre-exposure or postexposure vaccination regimen with HDCV, PCECV, or rabies vaccine adsorbed (RVA); or previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination. Persons who initiated but did not complete a rabies vaccine regimen are not considered to be “previously vaccinated.”

DHEC Contacts for Bite Reporting or Medical Consultation

During working hours, animal bites may be reported to the DHEC Bureau of Environmental Health Services Offices.  DHEC physicians are available for medical consultation to assist with rabies risk assessment.  Please call the number listed for the county of occurrence for assistance.  On nights, weekends or holidays, call 1-888-847-0902 and the answering service will route calls to the appropriate DHEC responder.

 

ANIMAL BITE REPORTS / MEDICAL CONSULTATION

 

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

864-227-5915

864-942-3680

864-372-3269

1-888-847-0902

AIKEN

803-642-1637

803-643-4027

803-576-2900

ALLENDALE

803-642-1637

803-643-4027

843-953-0038

ANDERSON

864-260-5585

864-222-3923

864-372-3269

BAMBERG

803-533-5490

803-268-5784

843-953-0038

BARNWELL

803-642-1637

803-643-4027

803-576-2900

BEAUFORT

843-846-1030

843-846-0604

843-953-0038

BERKELEY

843-953-0150

843-953-0151

843-953-0038

CALHOUN

803-533-5490

803-268-5784

843-953-0038

CHARLESTON

843-953-0150

843-953-0151

843-953-0038

CHEROKEE

864-596-3327

864-596-3920

864-372-3269

CHESTER

803-285-7461

803-285-5594

803-576-2900

CHESTERFIELD

843-661-4825

843-661-4858

843-661-4830

CLARENDON

803-778-6548

803-934-2938

843-661-4830

COLLETON

843-846-1030

843-846-0604

843-953-0038

DARLINGTON

843-661-4825

843-661-4858

843-661-4830

DILLON

843-661-4825

843-661-4858

843-661-4830

DORCHESTER

843-953-0150

843-953-0151

843-953-0038

EDGEFIELD

803-642-1637

803-643-4027

803-576-2900

FAIRFIELD

803-896-0620

803-896-0617

803-576-2900

FLORENCE

843-661-4825

843-661-4858

843-661-4830

GEORGETOWN

843-915-8801

843-915-6503

843-661-4830

GREENVILLE

864-372-3273

864-282-4371

864-372-3269

GREENWOOD

864-227-5915

864-942-3680

864-372-3269

HAMPTON

843-846-1030

843-846-0604

843-953-0038

HORRY

843-915-8801

843-915-6503

843-661-4830

JASPER

843-846-1030

843-846-0604

843-953-0038

KERSHAW

803-778-6548

803-934-2938

803-576-2900

LANCASTER

803-285-7461

803-285-5594

803-576-2900

LAURENS

864-227-5915

864-942-3680

864-372-3269

LEE

803-778-6548

803-934-2938

843-661-4830

LEXINGTON

803-896-0620

803-896-0617

803-576-2900

MARION

843-661-4825

843-661-4858

843-661-4830

MARLBORO

843-661-4825

843-661-4858

843-661-4830

MCCORMICK

864-227-5915

864-942-3680

864-372-3269

NEWBERRY

803-896-0620

803-896-0617

803-576-2900

OCONEE

864-638-4185

864-638-4186

864-372-3269

ORANGEBURG

803-533-5490

803-268-5784

843-953-0038

PICKENS

864-372-3273

864-282-4371

864-372-3269

RICHLAND

803-896-0620

803-896-0617

803-576-2900

SALUDA

864-227-5915

864-942-3680

803-576-2900

SPARTANBURG

864-596-3327

864-596-3920

864-372-3269

SUMTER

803-778-6548

803-934-2938

843-661-4830

UNION

864-596-3327

864-596-3920

864-372-3269

WILLIAMSBURG

843-915-8801

843-915-6503

843-661-4830

YORK

803-285-7461

803-285-5594

803-576-2900

**If you do not receive a response from the county medical consultation number during working hours, call the Division of Acute Disease Epidemiology: 803-898-0861 (8:30 a.m. – 5:00 p.m., M-F)

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.

Serologic Testing by Rapid 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 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. 
Per ACIP guidance, the Rapid Fluorescent Focus Inhibition Test (RFFIT) gives an indicator of adaptive immune response to rabies vaccination.  Complete virus neutralization at a 1:5 serum dilution by the RFFIT is an indicator of an adequate immune response. 

The medical plan for patients who are not vaccinated on schedule, do not demonstrate an adequate antibody response when tested, or are immunocompromised is best managed on a case-by-case basis incorporating consultation between the patient’s private provider, a DHEC Medical Consultant and the CDC Rabies Section Consultant.
DHEC does not provide the RFFIT. The following laboratories perform RFFIT:

CDC performs serologic testing with a more rapid turn-around-time than private labs, but CDC testing is only available through the request of the state health department. 

Manufacturers and Distributors of Rabies Biologics

Ordering rabies biologics will be simpler for health care providers that have established accounts with vaccine suppliers.  Contacts for vaccine manufactures and distributors are provided below to assist in locating rabies biologics.  Contact the DHEC Immunization Division at 803-898-0460 for assistance in ordering rabies PEP biologics if needed.

Human diploid cell vaccine

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

Purified chick embryo cell vaccine

RabAvert®
Contact Norvartis Vaccines and Diagnostics at 1-800-244-7668 to place an order
Website: https://www.novartisvaccinesdirect.com

Vaccine Distributor

  • 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

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

HyperRab™
Talecris Biotherapeutics
Phone: 1-800-243-4153
Website: http://www.talecris-pi.info
BDI Pharma – 1-800-948-9834

Patient Assistance Programs for Low-Income/Uninsured

Patient assistance programs are available through Sanofi Pasteur and Novartis for individuals that meet certain income eligibility criteria.  Sanofi Pasteur’s Patient Assistance Program is administered by the Franklin Group.  The Novartis program is administered by RX for Hope. For information about patient assistance programs and application forms, please refer to the following contact numbers and links:

Rabies Vaccine Information Sheet for Patients

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For comments about the Provider Guide, contact:  (803) 898-0798  Fax (803) 898-0557