Animal Bites and Other Potential Rabies Exposures 2 nd Quarter DIDE Training May 18, 2011

Objectives Understand the public health burden of animal bites and the purpose of surveillance Describe the epidemiology of animal bites in WV Review animal bite case management Review changes to animal bite form Review current WVEDSS-related issues

Background – Public Health Burden True incidence of animal bites is not known Estimated 3–6 million mammalian bites/year 1 –0.2–1.0% of ED visits (200,000–1,000,000 visits) 2,3 10% result in sutures, follow-up visits 1–2% result in hospitalization Small number of deaths (dogs bites result in 10–20 deaths per year in U.S.) 1 Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a problem?. Inj Prev. Oct 2008;14(5): Garcia, VF. Animal bites and pasturella infections. Pediatrics in Review. 1997;18:

Biting Species Multiple animal species account for bites to humans –Dogs (80–90%) –Cats (5–15%) –Rodents (2–5%) –Others

Background – Dog Bites Most bites are caused by dogs –Most opportunities for exposure 75 million dogs in U.S. 37% of households own >1 –Jaw pressure (200+ Psi) $100 million in hospital expenses 4 $1 billion in homeowner’s claims per year 4 4 Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;2711:51–53.

Potential Health Outcomes Psychological impact –Lifetime fear of animals –Nightmares/difficulty sleeping –Speech defects –Depression Physical damage/disfigurement –Avulsions –Lacerations –Punctures –Crushing

Potential Health Outcomes Risk of infection due to microorganisms –In the biter’s saliva (rabies virus, Pasteurella multocida, P. canis, etc.) –On the victim’s skin (Staphylococcus, Streptococcus spp., etc.) –In the environment (Clostridium tetani) Infection risk increases with –Species of animal (cat vs. dog, others) –Type of wound (puncture bites) –Delayed treatment (>24–48 hours) –Patient age >50 years

Animal Bite Surveillance in WV Reportable event per § and § –Animal bites and other potential rabies exposures –Rabies post-exposure prophylaxis (PEP) Local health dept –Follow-up of exposures –Case management –Report to DIDE via WVEDSS

Animal Bite Case Definition “A bite or scratch from a vector species or the introduction of saliva or central nervous system (CNS) tissue from a vector species into an open, fresh wound or mucous membrane (eye, mouth, or nose) of a human being.” Note: this includes bat exposures where a bite or scratch cannot be ruled out

Non-Exposures The following are examples of non-exposures –Petting an animal –Animal licking intact skin –Bite from an animal that had contact with a rabid animal –Contact with blood, urine and/or feces of an animal –Looking at a rabid animal…

Purpose of Animal Bite Surveillance Mitigate human risk of rabies Monitor epidemiology of animal bites Monitor PEP use/misuse

Epidemiology of Animal Bites Reported in WV, 2007–2009

RR*=0.1 (0.1–0.2) RR*=10.9 (8.2–14.5) RR*=9.4 (6.8–13.0) *compared to having exposure to any other animal

Rabies PEP Approximately 40,000 rabies PEP / yr in U.S. Cost is approximately $2,500 Risk of rabies is often uncertain but very low –High case-fatality of rabies with this uncertainty influences inappropriate administration of PEP

PEP Recommendations Zero risk (for true exposures) does not exist –Patient with healthcare provider make ultimate decision PEP recommendations should take into account: –Availability of animal for confinement or testing (and outcomes) –Circumstances of exposure –Type of exposure –Type of animal –Behavior of animal –Vaccination status of biting animal –Local rabies epidemiology

Case Management

Each case is a potential legal record The following should be documented –Patient demographics –Exposure information –Outcome of animal –Outcome of patient

Case Management Each case is a potential legal record The following should be documented –Patient demographics –Exposure information –Outcome of animal –Outcome of patient Public Health Actions

Report received

Verify victim info

Report received Verify victim info Ensure minimal patient info present: Name Address Age/DOB Sex Contact info Rabies vaccination status (previous to exposure)

Report received Verify victim info Verify exposure info

Report received Verify victim info Verify exposure info Ensure critical info present: Exposure date Exposure type Exposing species

Report received Verify victim info Verify exposure info Ensure critical info present: Exposure date Exposure type Exposing species Determine other details: Owned vs. non-owned animal Vaccinated vs. unvaccinated Provoked or unprovoked Normal or abnormal behavior County of exposure

Report received Verify victim info Verify exposure info Management of animal

Report received Verify victim info Verify exposure info Management of animal Confine / Observe Animal Dead Lost to Follow- up

Report received Verify victim info Verify exposure info Management of animal Confine / Observe Cat/dog/ferret: 10 days from exposure date Livestock: 14 days from exposure date Others: confine/observe not appropriate Animal Dead Lost to Follow- up

Report received Verify victim info Verify exposure info Management of animal Confine / Observe Document Outcome: Verified healthy Died Lost to follow-up Animal Dead Lost to Follow- up

Report received Verify victim info Verify exposure info Management of animal Confine / Observe Animal Dead Tested for rabies Not tested Lost to Follow- up

Report received Verify victim info Verify exposure info Management of animal Confine / Observe Animal Dead Document Test Result: Positive Negative Indeterminate Lost to Follow- up

Report received Verify victim info Verify exposure info Management of animal Confine / Observe Animal Dead Lost to Follow- up (Document)

Report received Verify victim info Verify exposure info Management of animal Status of victim

Report received Verify victim info Verify exposure info Management of animal Status of victim Document Outcome: Hospitalization Death Rabies PEP

Report received Verify victim info Verify exposure info Management of animal Status of victim Document Outcome: Hospitalization Death Rabies PEP RIG date Vaccine dates

Report received Verify victim info Verify exposure info Management of animal Status of victim Document recommendations, attempts to contact

Data Quality (2009) Completeness Timeliness Accuracy

Completeness of Demographic Fields (2009) VariablePercent Complete Patient name100% Date of birth100% County of residence99.8% Gender97.9% Race56.0% Ethnicity42.4%

Completeness of Exposure Fields (2009) VariablePercent Complete Exposure type99.8% Exposure date100.0% Exposure time of day62.7% Body location98.2% Exposure provoked85.9%

Completeness of Species Fields (2009) VariablePercent Complete Species involved99.9% Ownership (pet, stray or wild)97.4% Animal final outcome/status91.7% Breed (canine only)74.4% Vaccination history (pet only)50.7% Specimen submitted89.1% Specimen result (if submitted)95.5%

Completeness of Outcome Fields (2009) VariablePercent Complete Patient death100.0% Patient hospitalization96.2% PEP initiated85.8% PEP status46.2%

Transition to NBS As we move from WVEDSS to NBS we are making changes to forms –Shorter (most are one page front/back) –Disease-specific (no more “general” forms) Animal bite form revised early 2011, reviewed by NBS task team

Structure of New Forms Patient demographics Investigation summary Report Source/ Healthcare provider Clinical Vaccination Treatment Laboratory results Infection timeline Epidemiologic exposures Public health issues Public health actions

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