Animal and Bat Bites in King County

Health Care Providers
Clinical Assessment and Management of Potential Rabies Exposures in King County

Section 4 - General Principles of Rabies Exposure Management

1.	Assess rabies exposure using the appropriate decision tree. In general: If a bat or a wild carnivore (e.g. raccoon, skunk, or other) caused the exposure, but the animal is NOT available for rabies testing, the patient requires rabies post-exposure prophylaxis (PEP). If a bat or a wild carnivore caused the exposure, and the animal is available for testing, the animal should be tested for rabies before PEP is recommended (unless the bite was to the head area). When a human is exposed to a rabid animal, rabies infection is likely to occur more quickly if the face and neck were exposed to rabies virus. This is because the virus has a shorter path to the spinal cord and brain. Potential rabies exposures to the face and neck are of the highest priority for assessment and management. If exposed by a dog, a cat, or a ferret, and the animal can be identified and observed for 10 days after the exposure occurred, then the exposed patient should contact the appropriate animal control agency, and report the incident. This will assure that the animal is observed and confined. Animal control can also assess the rabies immunization status of the animal. If exposed by a dog, cat, or ferret, but the animal is not available for observation, use the decision tree to determine if PEP is indicated. Usually PEP will not be necessary in these situations, but each situation should be evaluated carefully. If exposed by a rodent, lagamorph (rabbit, hare), or livestock, use the decision tree to determine if PEP is indicated. Bites from these animals almost never require PEP. In all cases involving rodents, the health department should be consulted before a decision is made to initiate rabies PEP. For persons exposed while in a developing country, rabies PEP is generally indicated. Signs of rabies in animals - Behavior changes consistent with rabies include erratic conduct, unusual aggression, excitation, or agitation; difficulty with coordination and walking; depraved appetite (eating wood, soil, stones, plants, or other foreign objects); increased salivation, drooling or foaming at the mouth with head held characteristically downward; hoarse, throaty bark or snarl; muscular tremors or seizures (especially in cats); or dilated pupils, vacant stare. In some animals, rabies may cause varying degrees of paralysis, frequently beginning at the head or neck, causing jaws to hang open. At times, animals, particularly large animals (cows, sheep, goats) may develop paralytic or dumb rabies in which the animal is not agitated. In situations where consultation regarding animal behavior is needed to make the appropriate management decision, contact the Public Health Veterinarian at 206-263-8454.
2.	If post-exposure prophylaxis (PEP) is indicated, follow guidelines in Section 5.
3.	Treatment of wounds: Immediate and thorough washing of all bite wounds and scratches with soap and water and a virucidal agent such as a povidone-iodine solution are important measures for preventing rabies. In studies of animals, thorough wound cleansing alone without other post-exposure prophylaxis has been shown to reduce markedly the likelihood of rabies. Tetanus prophylaxis and antibiotics should be administered as indicated.
4.	Report to Public Health. Known or suspected exposure to rabies is a reportable condition. Please call Public Health to report a case: 206-296-4774.
5.	Laboratory testing of animals by the Public Health Laboratory is done when there is potential human exposure to rabies and the animal is available for testing. It is ESSENTIAL to notify Public Health (206-296-4774) in order for laboratory testing of animals to be arranged. Bats are generally tested at the Public Health Laboratory located at Harborview. Other animals are tested at the Washington State Department of Health Laboratory located in Shoreline.
6.	For any questions regarding the assessment of rabies exposure or management of suspected rabies exposure, call Public Health - Seattle King County: 206-296-4774.
7.	Insurance considerations. Most major insurers will cover rabies post-exposure prophylaxis when potential exposure to rabies is documented in the medical record. For patients who are paying privately, the cost of rabies biologics (rabies vaccine and rabies immune globulin) is approximately $1,500-2,000.
8.	Obtaining rabies vaccine and rabies immune globulin. Vaccine (HDCV) may be ordered by physicians from Aventis-Pasteur in Swiftwater, PA: 1-800-822-2463. Intramuscular (IM) doses are priced at about $160 per dose. RIG is supplied as 2.0 or 10.0 mL vials that contain 150 IU of rabies antibody per mL. The volume of RIG to be administered is dependent on the weight of the patient. The dosage is 20 IU/kg (0.133 ml/kg) or 9 IU/lb (0.06 ml/lb). Therefore, a person who weighs 100 lbs requires 6mL of RIG. RIG may be obtained from Aventis-Pasteur, Swiftwater, PA (1-800-822-2463) and from Bayer Biological Products, Research Triangle Park, NC (1-800-288-8371). The cost of RIG is ~$80/mL. RIG that remains from partially used vials should be discarded immediately. Please consider this when making an order.


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