Rabies Rhabdovirus Doriann Prasek RN, BSN, CIC Manager Infection Prevention Overlook Medical Center

Case Study: On 30 June 2011, a 73 year-old Haitian female with history of hypertension and diabetes mellitus type II presented to Emergency Department at OMC with right shoulder pain, chest pain, headaches, increased blood pressure and dysphasia. Ischemic heart disease was suspected, but ruled out. Emergency Department requested to evaluate patients dysphasia, however patient declined and said was able to drink water. She was released with pain medication, but returned to the Emergency Department the following day with shortness of breath, insomnia, and hallucinations. She was subsequently hospitalized due to deteriorating mental status.

 On July 7, the NJDHSS was notified of patient hospitalized with acute encephalitis in which rabies was being considered but no known animal exposure had occurred as family had no recollection.  Once arboviruses and other potential etiologies were ruled out, clinical samples were sent to the CDC for testing.  Rabies virus antigens were identified in a nuchal (neck by hair line) skin biopsy on the 18 th of July. Saliva was later found to be positive.  The patient’s neurologic status continued to deteriorate leading to her death on the 20 th of July. Case Study:

 After the rabies diagnosis was confirmed, family members in Haiti remembered that in April 2011, approximately 1 month before arriving in the United States, the patient had been bitten by a stray dog she had adopted. She did not consider the bite severe and did not seek medical attention.  Rabies strain dog/mongoose variant from Dominican Republic and Haiti.

Pathology Report CDC SpecimenTestResults Pituitary, Spinal cordRabies VirusPositive Liver, Spleen, Pancreas, GallbladderRabies VirusNegative Kidney, AdrenalRabies VirusNegative Esophagus, StomachRabies VirusNegative Muscle, SkinRabies VirusNegative Cervix, Uterus, Ovary, Fallopian TubeRabies VirusNegative Cortex, Paraventricle, Cerebellum, Brain Stem, Spinal Cord, Hippocampus Rabies VirusPositive

Starting on July 18, the risk for rabies virus exposure to healthcare workers were assessed through a questionnaire by NJDHSS and the hospital’s infection prevention program. Healthcare questionnaire was based on Risk Levels:  Nil to Zero- no exposure at all  Low-some known exposure or potential contact with infectious materials  Medium- Definite contact with infectious materials, but PPE practices were followed  High- Definite contact with infectious materials, with breaks in PPE practices. Or exposure to direct wound or mucosal contact with infectious materials, bites or scratches from patient. Recommendations for PEP:  High- yes  Medium- yes or no dependent on assessment of exposure  Low- probably not  Nil to Zero- no Evaluation of Healthcare Workers Exposure

Summary of Results: Two hundred and forty-six (246) healthcare workers were identified as having possible contact with the patient during ED visits and hospitalization. 10 (4%) received PEP  Of 10 healthcare worker:  5 had not followed standard infection prevention practices  2 had potential exposure to patient saliva at an open wound or mucous membrane  3 received PEP despite assessments of infection risks which were nil to low.

Things That Worked Well:  Rapid response and assistance from NJDHSS, Local Health Department and the CDC.  Open communication and education with Administration, Physicians and Staff.  Screening tool developed by the NJDHSS and CDC  Continuous feedback by regulatory agencies  Team work  All efforts combined decreased the numbers of worried well.

Lessons Learned:  This is the third report of human rabies in the US acquired in Haiti and highlights the importance of a detailed history of a patient with travel from a rabies- endemic country, and the utility of consultation with medical and public health professionals related to animal bites regardless of perceived severity.  Healthcare workers do not follow standard precautions  CDC recommended respiratory precautions with any respiratory inducing procedures.  When you say it can’t possibly be rabies, it is…..

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