A 19-year-old male came to clinic because of a possible bat bite. He lived in a home with 4 other college students, and a bat was found in his bedroom while he was studying. He caught the bat in his T-shirt and let it go outside. He was not wearing gloves. He said he might have been bitten but wasn’t sure, but he had washed his hands thoroughly afterwards and had discarded the T-shirt in the garbage. He had gone to work overnight and when he returned his roommates said they had found 4 other bats in the house. They were all going to the emergency room to be evaluated. The past medical history was non-contributory. He had not received rabies vaccine in the past and was current with his immunizations.
The pertinent physical exam showed a healthy male with normal vital signs. He had several scratches on his hands that he stated were from his cat and from working outside. None looked infected. The rest of his examination was negative. The diagnosis of significant bat exposure with possible rabies exposure was made. It had been many hours since the exposure and he had washed his hands several times but the physician did decide to thoroughly wash his hands with providine-iodine as it may help and wouldn’t hurt the patient to do it. As there was no obvious bite mark, human rabies immunoglobulin was not injected into a wound but was given in one arm. He was also given the initial rabies vaccination and return appointments for 3 more doses. The patient said that the landlord had been contacted and was going to have the house checked and the bats eliminated before he was going to return to living in it.
Rabies is an important zoonosis worldwide which causes progressive encephalomyelitis and a high fatality rate. About 55,000 people worldwide die annually. In the US, about 1-3 cases occur annually, but 20-30,000 people receive post-exposure prophylaxis (PEP) for rabies. Importantly, “PEP has never failed in the United States since the introduction of modern cell-derived vaccines in the 1970s.”
Any mammal is susceptible to rabies virus. While domesticated dogs are an important reservoir internationally, in the US other terrestrial mammals are more important with geographical differences. The most important animals are coyotes, fox, raccoon, and skunk. Mongoose is also important in Puerto Rico. Bats are also important reservoirs. From 2000-2007, 17 of 20 rabies cases that occurred in the US were from bats.
Rabies transmission from bats “… can occur from minor, seemingly unimportant, or unrecognized bites from bats.” Therefore contact should be minimized. PEP is considered for people who had significant contact, were known to be bitten or were in a room and might be unaware that the bat touched them or bit them. Examples would be a sleeping person or a child who was unattended and is now found to have a bat in the room. If the bat can be safely collected then it can be tested for rabies. If the bat is available for testing and is negative, then PEP is not indicated or can be stopped. If the bat is not available then PEP is given.
Treatment for rabies exposure includes wound cleansing with copious amounts of soap and water. Virucidal agents such as povidine-iodine should be used for wound irrigation if available. If the patient is previously unimmunized with rabies vaccine, human rabies immune globulin (20IU/kg weight) is infiltrated into and around the wound if at all possible. If not possible to give the entire dose in this location any remaining immune globulin is given as an injection intramuscularly. In a separate location, and in a separate syringe, rabies vaccine is also given. Approved locations for rabies vaccine is the deltoid area for adults and older children, and anteriolateral thigh for young children. The gluteal area is never used for rabies vaccine administration.
In 2011, the American Academy of Pediatrics updated their policy statement for rabies prevention. All previous recommendations were unchanged, except for previously unvaccinated immunocompetent people. Four doses of vaccine are now recommended to be given on day 0, 3, 7 and 14. Day 0 is the day dose 1 of vaccine is given. Before this recommendation, 5 doses of vaccine were administered.
Questions for Further Discussion
1. What are the rabies treatment recommendations for previously vaccinated individuals?
2. What PEP is recommended for people with occupational exposure such as veterinarians, animal control officers and roofers?
- Age: Young Adult
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MMWR. Compendium of Animal Rabies Prevention and Control, 2008, National Association of State Public Health Veterinarians, Inc. (NASPHV), April 18, 2008 / 57(RR02);1-9. Available from the Internet at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5702a1.htm (rev. 4/18/2008, cited 4/25/2011).
Centers for Disease Control. Bats. Available from the Internet at http://www.cdc.gov/rabies/exposure/animals/bats.html (rev. 3/22/2010, cited 4/29/2011).
Centers for Disease Control. Wildlife Reservoir for Rabies. Available from the Internet at http://www.cdc.gov/rabies/exposure/animals/wildlife_reservoirs.html (rev. 11/29/2010, cited 4/25/2011).
Committee on Infectious Diseases. Rabies-prevention policy update: new reduced-dose schedule. Pediatrics. 2011 Apr;127(4):785-7.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital