701 airmen identified for animal exposure

640 (91%) individuals contacted

(644 WBQ completed: 4 individuals with more than one exposure)

16 (2%) individuals referred to provider for

possible PEP

9 (56%) individuals received PEP

7 (44%) individuals did not require PEP;

determined by provider

19 (3%) assessments completed by the U.S.

Army with no PEP required

609 (95%) individuals did not require referral

to provider

61 (9%) individuals were unable to be reached (certified

letters mailed to last known address)

• Through the outreach, nine individuals needing PEP were identified and treated.• Locating individuals who were not full-time active duty (e.g., Air National Guard) or had

separated from the military was particularly challenging.

• Inadequate documentation in medical records resulted in the need for the majority of individuals to be contacted directly, consuming valuable time and resources.

• A more thorough review of PDHAs prior to returning home from deployment could have resulted in individuals receiving a more timely evaluation for animal exposures.

• Increased public health messages to deploying troops regarding rabies risk could reduce the incidence of contact with potential vectors.

The U.S. Air Force Response to the Deployment-Related Rabies Prevention Outreach Program

L DeMarcus¹, MPH; M Selent¹, DVM, MPH; L Marmer¹, MPH; S Zorich¹, MD, MPH; R Suman¹, BS; J Escobar¹, MPH; N Johns², DVM, MPH; P Gould², MD, MPH; A Costello², MD, MPH, FAAP; B Nishikawa¹, MD, MPH¹Epidemiology Consult Service, United States Air Force School of Aerospace Medicine, Wright-Patterson AFB, OH

²Air Force Medical Support Agency, Arlington, VA

ABSTRACT(revised)

Background: On 31 August 2011, the rabies-related death of a U.S. Army soldier prompted the Department of Defense to identify personnel who had indicated, on their post-deployment health assessment, having an animal exposure during any deployment since March 2010. The U.S. Air Force (USAF) followed up on 701 airmen to ensure their animal exposure was properly assessed.

Methods: An algorithm, based on recommendations by the Advisory Committee on Immunization Practices, was used to assist AF public health officials and medical providers in assessing individual exposures and treatment regimens. Direct patient interviews were conducted if records were incomplete. All individual reviews were documented using a web-based electronic questionnaire.

Results: Of 701 individuals, 580 required direct interviews. Potential rabies exposure was identified in 11 airmen and an additional 5 individuals were referred for further assessment. Among the 16 patients who were subsequently referred to a provider for post-exposure prophylaxis (PEP), 9 received treatment. Certified letters were sent to retired or separated individuals who could not be reached by phone (n=61), advising them to contact their provider.

Key FactsRabies is a zoonotic disease transmitted in saliva of rabid mammals through a bite or scratch, or through contact with mucous membranes.

Rabies has a highly variable incubation period from 1 to 3 months (average), but can range from days to years.

Symptoms include fever, anxiety, loss of appetite, difficulty swallowing, loss of coordination, blurred vision, and paralysis.

Once onset of symptoms appear, progression to death is rapid and almost inevitable (≈100% case fatality rate).

• 7 documented cases of survivors

Over 55,000 people die of rabies annually.• 95% of deaths occur in Asia and Africa

Estimated cost in U.S. (detection, prevention, & controls) : >$300 million annually

Rabies in U.S.: Human infections typically occur from unknown rabies exposure (e.g., bat bite while sleeping).

Rabies in developing countries: Canines contribute to 99% of human rabies infections.

Last rabies-related death in a U.S. service member occurred 24 Oct 1974 from a dog bite in the Philippines.

With rabies vaccinations and PEP, rabies is 100% PREVENTABLE.

NOTE: Providers who have questions or concerns regarding application of this algorithm should contact their local Rabies Advisory Board for assistance.

NO Rabies PEP Indicated Document the incident and clinical assessment in AHLTA.

NO Rabies PEP Indicated Document the incident and assessment in AHLTA. Code exposure³ and use

supplemental code E906 for dog bite.

Did the patient have contact DURING THE LAST 18MONTHS with a mammal capable of spreading rabies?2

Did the patient sustain a bite that broke the skin, have wet animal saliva contact mucous membranes or broken skin, or have a bat in sleeping quarters?

Was the animal a U.S./NATO military working dog?

Was the animal directly observed for 10 days following the exposure and appeared healthy at day 10?

Rabies PEP Indicated 0 doses of vaccine: Administer both human rabies immunoglobulin (HRIG) and rabies vaccine regardless of

time since incident.

1 dose of vaccine: Restart vaccine series. No HRIG indicated. (HRIG should not be given more than 7 days after first vaccine dose if the patient already received some rabies vaccine.)

2 doses of vaccine: Administer 2 doses of rabies vaccine, 7 days apart (3rd and 4th dose). Draw a titer on the 7th day to assess immune status.7

3 doses: Administer 1 dose of rabies vaccine and draw a titer for assessment of immune status.7

4+ doses: no PEP indicated.

Document exposure incident, assessment, and treatment in AHLTA. Use appropriate wound code and supplemental E codes, as well as code V04.5.3 Document HRIG and rabies vaccines in Air Force Complete Immunization Tracking Application.

NO

NO/UNSURE

YES

NO Rabies PEP Indicated Document the incident and assessment in AHLTA. Code exposure³ and use

supplemental E codes as appropriate.YES

YES

Is appropriate rabies post-exposure prophylaxis (PEP) (4 doses of vaccine) for this exposure documented in the medical record?4

NO

NO Rabies PEP Indicated Document the incident and assessment in AHLTA. Code exposure³ and use

supplemental E codes as appropriate.YES

NO/UNSURE

YES/UNSURE

Air Force Modified Deployment-Related Rabies Outbreak Algorithm: Evaluation and Treatment of Potential Deployment-Related Rabies ExposuresIMPORTANT: THIS ALGORITHM SHOULD NOT BE USED TO EVALUATE ACUTE BITES OR EXPOSURES1

1. For acute bites and exposures, refer to http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm and http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm.

2. Dogs, cats, bats, raccoons, skunks, ferrets, foxes, mongooses, jackals, and other medium to large ‐ ‐mammals. Rodents are not reservoirs of rabies virus. Small rodents (e.g., squirrels, chipmunks, rats, mice, hamsters, guinea pigs, and gerbils) and lagomorphs (including rabbits and hares) are rarely infected with rabies and have not been known to transmit rabies to humans.

3. Use codes 870.0 897.7 (wound, open) or 910 919 (superficial injury codes) with the appropriate ‐ ‐supplemental code E906 for dog bite or E906.5 for injuries due to monkey or other animal. Include code V04.5 for animal bite requiring rabies vaccination.

4. See protocols on page 2. Note: as these exposures are historic, consider 4 doses of human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) adequate for PEP, regardless of whether the patient was on antimalarials. Patients with 3 or fewer doses of vaccine should be contacted and brought in for additional PEP.

5. If vaccine doses were missed, restart the vaccine series.6. PCECV should not be given to individuals with egg allergies. HDCV is safe in egg allergic individuals.‐7. If titer <1:5, call USAFSAM for further guidance.

Background

Methods

• A public health investigation was initiated when a soldier died on 31 Aug 2011, after receiving a rabid dog bite during a recent deployment.

• The investigation revealed members of the soldier’s unit also received animal bites during their deployment and were not thoroughly assessed.

• Each branch of the military worked together to identify all potential animal bite exposures during the recent deployment and properly assess all exposures.

• USAF School of Aerospace Medicine Epidemiology Consult Service (USAFSAM/PHR) led the USAF Deployment–Related Rabies Prevention Outreach.

• All deployers are routinely administered two assessments, which we used as the main sources to identify those reporting animal exposure:

1) Post-Deployment Health Assessment (PDHA) (completed <7 days to redeployment)2) Post-Deployment Health Reassessment (PDHRA) (completed 90-180 days from return of

deployment)

• Outreach was part of a coordinated effort with the other branches of the military.

• USAFSAM/PHR coordinated through the AF Major Commands for each AF installation to assist in reaching out to individuals identified in the investigation currently assigned to their installation.

• Instructions were created to assist Public Health offices in assessing individual exposures. • If medical records documented proper evaluation and treatment (if required) regarding

animal exposure, then no direct patient contact was needed.

• Each individual was tracked through the use of a web-based questionnaire (WBQ) to assess the nature of the animal exposure.

Results

Non-Rabies Vector ExposuresAnimal Count

Insect 218Rodent 10

Multiple 2

Fish 1

Jellyfish 1

TOTAL 232Miscellaneous exposures include exposure to dead animals or having contact

with animals with no mention of injury

Multiple includes individuals who indicated more than one exposure to various rabies vectors.

73 individuals had potential rabies exposures (4 individuals had multiple exposures bringing total potential exposures entered into WBQ to 77)

Conclusions, Challenges, and Recommendations

Global Distribution of Risk Level for Humans Contracting Rabies, 2009

References:

CDC. Imported Human Rabies in a U.S. Army Soldier – New York, 2011. MMWR 2012; 61: 302-305.CDC. Use of a Reduced (4-Dose) Vaccine Schedule for Postexposure Prophylaxis to Prevent Human Rabies.

Recommendations of the Advisory Committee on Immunization Practices. MMWR 2010; 59:No. RR-2.

In the News…

U.S. Army Public Health Command Educational Poster

Reasons for No Provider Referral Count Not a true rabies exposure (e.g., bit by non-rabies vector, incorrectly completed PDHA or PDHRA, etc.) 546

Animal exposure did not cause a bite that broke the skin, a scratch that bled, or had animal saliva that contacted mucous membrane or broke skin

29

Animal was a U.S./NATO military working dog 17 Documentation from previous evaluation determined PEP required and appropriate treatment completed 10

Animal observed healthy at least 10 days after exposure 5 Documentation from previous evaluation determined PEP not required 2

TOTAL 609

• Total number of individuals who were tracked throughout the assessment to determine if PEP was necessary

Conclusions: Despite the success of the outreach, the investigation accentuated the need for more emphasis on education prior to deployment about rabies awareness and prevention. Additionally, the paucity of complete medical records necessitated contacting the majority of individuals, which consumed considerable time and resources; therefore, improved medical record documentation should be a priority.

Rabies PEP schedule — United States, 2010 Vaccination status Intervention Regimen* Not previously vaccinated Wound cleansing All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent (e.g., 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 at an anatomical site (intramuscular [IM]) distant from vaccine administration. Also, HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of rabies virus antibody, no more than the recommended dose should be administered.

Vaccine HDCV or PCECV 1.0 mL, IM (deltoid area†), 1 each on days 0,§ 3, 7, and 14. A fifth dose on day 28 is required if patient is immunosuppressed or on antimalarials.

Previously vaccinated** Wound cleansing All PEP 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.

HRIG HRIG should not be administered.    Vaccine HDCV or PCECV 1.0 mL, IM (deltoid area†), 1 each on days 0§ and 3. * These regimens are applicable for persons in all age groups, including children. † The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh may be used. Vaccine should never be administered in the gluteal area. § Day 0 is the day dose 1 of vaccine is administered. ** Any person with a history of pre-exposure vaccination 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.

Source: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm

Disclaimer:

The views expressed are those of the contributors and do not reflect the position of the U.S. Air Force, U.S. Department of Defense, or the Department of Homeland Security. Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2012-5293, 10 Oct 2012

Section 1: PEP Status

Section 2: Exposure Types

Section 3: Patient Interviews

90%

7% 3%

Did you interview the patient?

Yes

No, Records review only

No, Completed by Army

• Only 45 medical records were complete, which required direct contact with 580 individuals

• U.S. Army completed 19 assessments; medical record status unknown

BITE

SCRATCH

MUCOUS MEMBRANES

MISC0

5

10

15

20

25

30

35

40

Potential Rabies Exposures IdentifiedDuring Outreach by Animal Vector and Method of Exposure

(n=77)

MULTIPLE DOG CAT CAMELCOYOTE FOX GOAT MONKEY

Multiple includes individuals who indicated more than one exposure to various non-rabies vectors already listed in the

chart.