BU Rabies Safe Operating Procedures (SOPs)

Boston University 3/23/04

STANDARD OPERATING PROCEDURES

Rabies Protection Program

1. SCOPE

Rabies is a viral infection of the central nervous syst em.  It is typically transmitt ed by the introduction of saliva

or neural tissue from an infect ed animal into open cuts or wounds or via percutaneous exposure (i. e. scratches,

punctures or bites).  An effect ive rabies virus vaccination is available and is offer ed free of charge to

employees who have pot ential exposure to rabies virus in their work at Boston University or Bost on Medical

Cent er.  This Standard Operating Procedure (SOP) establishes a system of infor mation and safeguards that

should be followed at Boston Universit y when working wit h the rabies virus or animals known to carry rabies

in the research environment.

2. PROCEDURE

2.1 AGENT

Rabies virus (genus Lyssavirus, family Rhabdoviridae)

Rabies is an acute, fatal, incurable infect ious disease that is caused by an RNA virus.

2.2 LABORATORY AND RESEARCH HAZARD

The typical rout e of transmission in the research environment involves virus­laden saliva or neural

tissue from an infect ed animal introduced via a bite, scratch, or break in the skin or mucous

membrane.  Two document ed cases of laboratory transmission have involved aerosol transmission in

work wit h attenuated strains of rabies virus.  Although an instance of possible airborne transmission

was reported in a cave in Texas in 1956, this was not definitively confir med.  It occurred after

exposure t o caves inhabit ed by several million bats, of which a small percentage wer e infect ed wit h

rabies.  One researcher had chronic skin lesions on his neck, unrelated to contact wit h bats, and may

have been exposed in this way.  Anot her worker, who had visit ed the cave in which airborne

transmission was postulated had blood on his face after one of the cave visits, but could not

remember being bitt en by a bat.  Later experiments to test for airborne exposur e wer e inconclusive

(Messenger et al., 2003).  Two cases of rabies have been attributed to airborne exposures in

laboratories, and t wo cases of rabies have been attributed to probable airborne exposures in a cave in

Texas occupied by bats.

The viral agent may be present in all tissues of infect ed animals, with highest tit ers present in the central

nervous syst em t issue, salivary glands, and saliva.  Accidental parent eral inoculation, cuts, or sticks wit h

contaminated laboratory equipment, bites by infect ed animals, and exposure of mucous membranes or

broken skin to infect ious tissue or fluids are the most likely source of exposure for laboratory and

animal care personnel.  Infectious aerosols have not been a demonstrated hazard to personnel working

with clinical material, conducting diagnostic examinations, or in field situations.

Types of Exposures:

Rabies is transmitted only when the virus is introduced into open cuts or wounds in skin or onto

mucous membranes.  If there has been no exposure (as described in this sect ion), post­exposure

treatment is not necessary.  The likelihood of rabies infection varies wit h the nature and ext ent of

exposure.  Two categories of exposur e (bit e and non­bite) should be consider ed.

The risk of rabies after a bite by a rabid animal (5­80%) to an exposed individual is about 50 times

the risk after a scratch (0.1­1.0%).  The risk of rabies after contamination of minor wounds with

infect ed saliva is very low (<1%).  The risk after bites depends on t he sever ity of the bit e (80% after

mult iple bit es by rabid wolves) and the sit e of exposure.  The risk of rabies after bit es on the lower

extr emities (5%) or bites on upper extremities (25%) is markedly less that the risk after a bite to the

head (60%).  All of these risk estimat es are in the absence of post­exposur e prophylaxis and are

largely based on 19 th century hist orical recor ds.

Bite

Any penetration of the skin by teet h constitut es a bite exposure.  All bit es, regardless of location,

represent a potential risk of rabies transmission.  Bit es by some animals, such as bats, can inflict

minor injury and thus be undet ect ed.  Bit es to the face and hands carry the highest risk, but the sit e

of the bit e should not influence t he decision to begin treatment.

Strains of bat rabies have been document ed in Massachusetts since 1961, and infect ed bats have

been identified t hroughout the state. Since 1920, 92% of the 26 domestically acquir ed rabies cases

in humans in the U.S. have involved bat rabies.  Of those infect ed wit h bat rabies, a history of

exposure t o a bat was not document ed in 88% of cases.  This finding suggests that even limit ed

contact with bats may be associated with transmission.  Bat bites may be less sever e, and ther efor e

mor e difficult to recognize that bites from larger animals.  Post­exposure prophylaxis should be

given in a situation wher e a bat is physically present and a bite, or any ot her exposure/contact,

cannot be ruled out.  Bats captured following a human exposure should never be released.  Bats

captured should undergo testing for rabies.

Nonbite

Nonbite exposures from terrestrial animals rarely cause rabies.  Occasional reports of transmission

by nonbit e exposur es suggest that such exposures const itute sufficient reason to consider

post exposur e prophylaxis.  The nonbit e exposures of highest risk appear to be among persons

exposed to large amounts of aerosolized rabies virus and surgical recipients of cor neas transplant ed

from patients who died of rabies.

The contamination of open wounds abrasions, mucous membranes, or theoret ically, scratches wit h

saliva or other potent ially infectious materials (such as neural tissue) also const itut es a non­bit e

exposure.  If the material containing the virus is dry, the virus can be consider ed noninfectious.

Other contact by itself such as petting a rabid animal or contact wit h the blood, urine, or feces (e.g.,

guano) of a rabid animal does not in itself constitut e an exposure and is not an indication for post­

exposure prophylaxis.  Alt hough occasional reports of transmission by non­bit e exposure suggest

that such exposures may constitut e sufficient reason t o init iate post­exposur e prophylaxis under

some circumstances, non­bit e exposures rarely cause rabies.  Because the rabies virus is inact ivat ed

by desiccation and ultraviolet light irradiation, in general, if the mat erial containing the virus is dry,

the virus can be consider ed noninfectious.

Situations with little or no risk include petting a rabid animal or coming int o contact with an

animal’s blood, urine, feces, or skunk spray and do not requir e prophylaxis, unless the animal is a

bat, because bat bites may be less sever e and go unr ecognized.  If these body parts or secr etions are

mixed with saliva, the exposur e should be evaluated accordingly.

Human­to­Human

Ten cases of human­t o­human transmission of rabies have been r eport ed.  Eight occurred in

recipients of transplanted corneas in Thailand, India, the Unit ed States, Iran and France.  Stringent

guidelines for acceptance of donor cor neas have reduced this risk.  In addition to corneal transplants,

two cases of human­t o­human transmission, one from a bite and one from kissing occurred in

Ethiopia.  Stringent guidelines for acceptance of donor corneas have been implement ed t o reduce

risk.  Routine deliver y of healt h care to a patient wit h rabies is not an indication for post exposur e

prophylaxis unless exposure to mucous membranes or non­intact skin to pot entially infect ious body

fluids has occurred.  Adher ence t o standards will minimize the risk of airborne exposure.

EVALUATING EXPOSURES TO WILD AND DOMESTIC ANIMALS

Decisions to give post exposure prophylaxis after humans post­exposure prophylaxis after a human has been

exposed to a potent ially rabid animal should be based on the following:  (1) whet her the animal is high­risk

or a low­risk animal, (2) the healt h of the animal, i.e., whet her it is exhibiting signs consist ent with rabies,

(3) the availability of the exposing animal for testing or if it is a domest ic animal (dog, cat, ferret) or

livestock (cattle, horse or sheep), for quarantine, (5) type of exposure, and (6) knowledge of the

epidemiology of rabies in the area. Now that raccoon and bat rabies are found throughout Massachusetts, all

of Massachusetts is consider ed endemic for animal rabies, and exposure should be evaluat ed with t his in

mind.

Animal with rabies can appear aggressive (“furious rabies”) or nor mal or meek (‘dumb rabies”).  Common

signs of rabies include neurological signs such as paralysis and ataxia, and hypersalivation.  Rabies can be

shed in saliva for days before signs of rabies appear.  Ther efor e, the behavior of the animal, is NOT a

reliable indicator of whet her or not the human exposed,  is at risk.

Animal Rabies Epidemiology and Evaluation of Involved Species

Bats

Rabid bats have been document ed in the 49 continental states, and bats are incr easingly implicated

as important wildlife r eservoirs for variants of rabies virus transmitt ed to humans.  Recent

epidemiologic data suggest that transmission of rabies virus can occur from minor, seemingly

unimportant, or unrecognized bit es from bats.  The limited injury inflict ed by a bat bite (in contrast

to lesions caused by terrestrial carnivores) and an oft en­inaccurate recall of the exact exposur e

history might limit the abilit y of healt h­care providers to det er mine t he risk of rabies result ing from

an encount er with a bat. Human and domestic animal contact with bats should be minimized, and

bats should never be handled by untrained and unvaccinated persons or be kept as pets.

In all instances of pot ential human exposures involving bats, the bat in quest ion should be safely

collect ed, if possible, and submitted for rabies diagnosis.  Rabies post exposure prophylaxis is

recommended for all persons wit h bit e, scratch, or mucous membrane exposure to a bat, unless the

bat is available for test ing and is negative for evidence of rabies. Postexposure prophylaxis might be

appropriate even if a bite, scratch, or mucous membrane exposure is not apparent when there is

reasonable probability that such exposure might have occurred.

On the basis of the available but somet imes conflicting infor mation from t he 21 bat­associat ed cases

of human rabies reported since 1980, in 1­2 cases, a bite was reported; in 10­12 cases, apparent

contact occurred but no bit e was det ect ed; and in 7­10 cases, no exposure to bats was reported, but

an undet ect ed or unreported bat bite remains the most plausible hypothesis.  Clustering of bat­

associated human cases wit hin the same household has never been r eported.  Consequently,

post exposur e prophylaxis should be consider ed when direct contact bet ween a human and a bat has

occurred, unless the exposed person can be certain a bite, scratch, or mucous membrane exposure

did not occur.  In instances in which a bat is found indoors and ther e is no hist ory of bat­human

contact, the likely effectiveness of postexposur e prophylaxis must be balanced against the low risk

such exposures appear to present.  In this setting, post exposure prophylaxis can be consider ed for

persons who wer e in the same room as the bat and who might be unaware that a bite or dir ect contact

had occurred (e.g., a sleeping person awakens to find a bat in the room or an adult wit nesses a bat in

the room wit h a previously unattended child, mentally disabled person, or intoxicat ed person) and

rabies cannot be ruled out by testing the bat.  Postexposure prophylaxis would not be warranted for

ot her household members.

Wild Terrestrial Carnivores

Raccoons, skunks, foxes, and coyot es are the terrestrial animals most oft en infect ed wit h rabies.  All

bit es by such wildlife must be consider ed possible exposures to the rabies virus.  Postexposure

prophylaxis should be initiated as soon as possible after  patients are exposed to wildlife unless the

animal has already been t est ed and shown not to be rabid.  If postexposure prophylaxis has been

init iated and subsequent immunofluor escence t esting shows that the exposing animal was not rabid,

post exposur e prophylaxis can be discontinued.

Signs of rabies among wildlife cannot be int erpret ed reliably; therefore, any such animal that

exposes a person should be euthanized at once (wit hout  unnecessary damage to t he head) and the

brain should be submitt ed for rabies testing.  If the results of test ing are negative by

immunofluorescence, the saliva can be assumed t o cont ain no virus, and the person bitten does not

requir e post exposure prophylaxis.

Other Wild Animals

Small rodents (e. g., squirrels, hamst ers, guinea pigs, gerbils, chipmunks, rats, and mice) and

lagomorphs (including rabbits and hares) are almost never found to be infect ed wit h rabies and have

not been known to transmit rabies to humans.  From 1990 through 1996, in areas of the country

wher e raccoon rabies was enzootic, woodchucks account ed for 93% of the 371 cases of rabies

among rodents reported to CDC.  In all cases involving rodents, the state or local health department

should be consult ed before a decision is made to init iate ant irabies post exposure prophylaxis.

The offspring of wild animals crossbred to domestic dogs and cats (wild animal hybrids) are

consider ed wild animals by the National Association of State and Public Healt h Vet erinarians

(NASPHV) and t he Council of State and Territorial Epidemiologists (CSTE).  Because the period of

rabies virus shedding in these animals is unknown, these animals should be euthanized and t est ed

rather than confined and observed when they bit e humans.  Wild animals and wild animal hybrids

should not be kept as pets.  Animals maintained in Unit ed States Department of Agriculture­

licensed research facilities or accredit ed zoological parks should be evaluated on a case­by­case

basis.

Domestic Dogs, Cats, and Ferrets

The likelihood of rabies in a domest ic animal varies by region; hence, the need for postexposure

prophylaxis also varies.  In the cont inental Unit ed States, rabies among dogs is report ed most

commonly along the Unit ed States­Mexico bor der and sporadically in areas of the Unit ed States wit h

enzoot ic wildlife rabies.  During most of t he 1990s, more cats than dogs wer e reported rabid in the

Unit ed States.  The majorit y of these cases wer e associated with the epizoot ic of rabies among

raccoons in the easter n Unit ed States.  The large number of rabies­infect ed cats might be attributed

to fewer cat vaccination laws, fewer leash laws, and the roaming habits of cats.  In many developing

countries, dogs are the major vector of rabies; exposur es to dogs in such countries repr esent an

incr eased risk of rabies transmission.

On the basis of new infor mation regarding rabies pathogenesis and viral shedding patterns in ferrets,

ferrets are now considered in this category wit h dogs and cats rather than as wild terrestrial

carnivor es.  A healt hy domestic dog, cat, or ferret that bit es a person may be confined and observed

for 10 days.  Any illness in the animal during confinement or befor e release should be evaluated by a

vet erinarian and report ed immediat ely to the local public healt h department.  If signs suggest ive of

rabies develop, the animal should be eut hanized and its head removed and shipped, under

refrigeration, for examination by a qualified laboratory.  If the biting animal is stray or unwant ed, it

should either be observed for 10 days or be eut hanized immediat ely and submitt ed for rabies

examination.

Circumstances of Biting Incident and Vaccination Status of Exposing Ani mal

An unprovoked attack by an animal is mor e likely than a provoked attack to indicate that the animal is rabid.

Bit es inflict ed on a person attempt ing to feed or handle an apparently healt hy animal should generally be

regarded as provoked.  A current ly vaccinated dog, cat, or ferret is unlikely to become infect ed wit h rabies.

2.3 LABORATORY RESEARCH PRECAUTIONS

Biosafet y Level 2 (BSL 2) practices and facilities are recommended for all activit ies utilizing known or

potentially infectious material.  BSL 2 practices include:  limit ed access, biohazard warning signs,

sharps precautions, biosafet y manual defining waste decontamination or medical surveillance policies.

BSL 2 facilities Immunization is recommended for all individuals prior to working wit h rabies virus or

with infect ed animals, or engaging in diagnost ic, production, or research activit ies wit h rabies virus.

Immunization is also recommended for all individuals ent ering or working in the same room wher e

rabies virus or infect ed animals are used.  While it is not always feasible to open the skull or remove t he

brain of an infect ed animal wit hin a biosafety cabinet, it is pertinent to wear heavy protective gloves to

avoid cuts and scratches, and face shields to protect the eyes nose and mout h from exposure to

infectious droplets or tissue fragments.  Primary containment and personal precautions, as described for

BSL 3 may be indicated for activities wit h high pot ential for droplet or aerosol product ion, and for

activities involving product ion quant ities for concentrations of infect ious mat erials.  Animal Biosafet y

Level (ABSL) 2 applies to live animals with pot ential rabies exposure.  See attachment 5, at end of this

document for BSL and attachment 6 for ABSL level requirements.

2.4 EMPLOYEES AT RISK

Naturally or exper imentally infect ed laboratory animals, their saliva, and their tissues are pot ent ial

sources of infect ion to laboratory and animal care personnel.  Such personnel are also at risk of

acquiring rabies infection from working wit h the rabies virus, from dir ect contact wit h quarantined

animals pot entially infect ed wit h rabies, from exposur e to pot entially infect ed animal tissues, and from

work involving the capture or destruction of pot entially infect ed wild animals.  This includes researchers

who are capturing animals for ecological studies that have low incidence of rabies.

RISK ASSESSMENT (see Attachment 4)

2.4.1 Continuous Risk Category

2.4.1.1 Nature of Risk – Virus present continuously, oft en in high concentrations.  Specific

exposures likely to go unrecognized. Bit e, non­bit e, or aerosol exposure.

2.4.1.1 Typical Populations – Rabies research laboratory workers and rabies biological product ion

workers.  This categor y includes all individuals involved in experiments using rabies virus

and all animal care staff handling animals that have been infect ed wit h the rabies virus.

2.4.2 Frequent Risk Category

2.4.2.1 Nature of Exposure – Exposure is usually episodic, wit h source recognized, but exposur e

also might be unr ecognized. Bit e, non­bit e or aerosol exposure.

2.4.2.2 Typical Populations – Rabies diagnostic lab workers, spelunkers, vet erinarians and animal­

control and wildlife workers in areas with rabies rates.  Vet erinarians and staff, and animal­

control and wildlife workers in rabies­enzoot ic areas.  Potent ial exposur e due t o the

manipulation of wild animal species known to harbor rabies virus, including but not limit ed

to bats, dogs, cats, ferrets, and wild terrestrial carnivor es.  Staff that handle wild or

quarantined cats, dogs, ferrets or other wild species known to harbor rabies virus are

included.  Includes wild species that are known to harbor rabies virus and that will not be

identified as such by quarantine.

2.4.3 Infrequent Exposure Category

2.4.3.1 Nature of Exposure – Exposure nearly always episodic with source recognized:

bite, or non­bit e exposure.

2.4.3.2 Typical Populations – Vet erinarians and animal­control and wildlife workers in areas of low

rabies rates.  Vet erinary students.  Travelers visiting areas wher e rabies is known to be

enzoot ic and immediat e care is unavailable.  This category includes vet er inarians and

animal care staff who will only handle purpose­br ed or post­quarantine wild animals that

have not been infect ed with the rabies virus.  Rodents including squirrels, hamst ers, guinea

pigs, gerbils, chipmunks, rats, mice, hares, rabbits that are rarely infect ed wit h the rabies

virus have not been known to transmit rabies to man.

2.4.4 Rare Exposure Category

2.4.4.1 Nature of Exposur e – Exposure always episodic wit h source recognized.  Bit e or non­bit e.

exposure.

2.4.4.2 Typical Populations – U.S. population at large, includes persons in rabies­epizoot ic areas.

2.5 PRE­EXPOSURE PROPHYLAXIS

Purpose: The purpose of pre­exposur e vaccination is t o simplify post­exposur e prophylaxis in those at

risk of exposure and should be consider ed for a number of at risk groups.  Anyone who has received

pre­exposure prophylaxis wit h rabies vaccine and who is later bitten or exposed MUST also receive

post­exposure prophylaxis.

Safety: All anti­rabies products licensed in the U.S. are safe and effect ive and cannot cause rabies.  Pre­

exposure vaccination of immunosuppressed persons is not recommended.

Continuous Risk Category

2.5.1.1   These individuals are requir ed to under go a primary course of vaccination wit h ser ologic

levels of rabies antibodies monit ored every six mont hs.  Vaccination requir es three doses of

human diploid cell vaccine (1.0 ml HDCV) given intramuscularly in the deltoid.  Vaccine is

given on days 0, 7 and 21 or 28.

Cheryl Barbanel, MD, MBA, MPH, FACOEM Page 7

2.5.1.2   Thereaft er, persons in the cont inuous risk category will under go ser ological t esting for rabies

antibody using the rapid fluor escent focus inhibit ion test (RFFIT) ever y six months.  Boost er

doses of vaccine are administ ered if antibody tit er is below a serum tit er corresponding to

complet e neutralization at a 1:5 serum dilution.

2.5.2 Frequent Risk Category

2.5.2.1 Individuals in the fr equent risk category are requir ed to under go a primary course of

vaccination wit h the human diploid cell vaccine (1.0 ml HDCV) given intramuscularly in the

delt oid.  Vaccine is given on days 0, 7 and 21 or 28.  Ther eaft er, persons in the fr equent risk

category will undergo serological for rabies antibody using the rapid fluorescent focus

inhibition t est (RFFIT) every t wo years.  Boost er doses of vaccine are administ ered if serum

tit er is below complet e neutralization at a 1:5 serum dilution.

2.5.3 Infrequent Risk Category

2.5.3.1 Animal users as defined in the infr equent risk category are offered rabies vaccination as the

primary course as list ed above.

2.5.3.2 It is not recommended that those in the infr equent risk category have ser ologic t esting or

boost er vaccination.

2.5.4 Rare Risk Category – No vaccination necessary.

2.6 POST EXPOSURE PROPHYLAXIS (see Attachment 1  (PDF), Attachment 2 (PDF), and

Attachment 3 (PDF).

FIRST AID:  The exposed individual should immediately cleanse the wound with soap and water

and a viricidal agent, such as a povidone­iodine solution.   Exposed mucous membranes should

be irrigated with potable water for 15 minutes.  Tetanus­dipht heria boost er should be given if

gr eater than 5 years since last dose of tetanus.  Prophylactic antibiot ics should be administ ered as

indicated.  Suturing must be evaluat ed by weighing cosmetic factors against the risk of bact erial

infection.

2.6.1 The individual should report the exposure t o their supervisor and to the appropriate

occupational healt h clinic.  For int ernational travel cont act International SOS at 1­800­523­

6586 (24 hours a day) ask to speak to the nurse.  Please make arrangements before travel.

2.6.1.2 Rabies exposur es occurring on the job but outside of the Bost on Universit y Campus should be

treated emer gently at the nearest hospital emer gency room.  Call Int ernational SOS at 1­800­

523­6586, 24 hours a day service to locate appropriate facilities in advance of travel if travel is

int ernational.

2.6.2 Aft er wound cleansing, a previously vaccinated individual should be inject ed

intramuscularly wit h 1.0 ml of HDCV on Day 0.  An addit ional 1.0 ml intramuscular

inject ion of HDCV should be given on day 3 post­exposure.

2.6.3          Aft er wound cleansing, an unvaccinated individual should receive a dose of human rabies

immunoglobulin HRIG (20 IU per kilogram body weight). If anatomically feasible, the

full dose should be infiltrated around the wound.  Any remaining volume should be

administ er ed intramuscularly at an anatomical sit e distant from the sit e of subsequent vaccine

administration. In addit ion, intramuscular injections in the deltoid area of 1.0 ml HDCV are

to be admi nistered at the time of exposure (day 0) and post exposure on days 3, 7, 14 and

28.

Off­schedule Post­Exposure Prophylaxis:  During the first 2 weeks if an individual misses

and of the doses, adjust the schedule so that t individual receives 4 doses in the first 14 post

exposure days.  The fift h dose can be given at 28 days post exposure.  If an individual misses

any doses in the second 2 weeks consult the manufacturer and adjust the schedule accordingly.

The fift h dose can be given at 28 days or mor e days following the initiation of post­exposure

prophylaxis. Do not give live­virus vaccines for 4 mont hs following t he administration of

HRIG.

Post­exposure Prophylaxis Reporting and Consultations:  The initiation of rabies

prophylaxis must be reported the Massachusetts Department of Public Health (105 CMR 140).

In the Cit y of Boston, providers are request ed t o report to the Bost on Public Healt h

Commission.  Appropriate for ms can be obtained form the Division of Epidemiology and

Immunization at (617) 983­6900.  The Division of Epidemiology is also available for

consultation about exposures:  at the above number on weekdays and at (617) 983­6200 on

evenings/ weekends for emer gencies.

Reporting Exposures: In or der to facilitate animal control effort (quarantine and eut hanasia)

all animal bit es should be report ed as follows:

officials.

1.  For human exposures to domest ic animals ot her than ferrets:  Bureau of Animal

Health, Department of Food and Agriculture at (617) 626­1794.

2.  For human exposures to ferrets:  Division of Fisheries and Wildlife,

Department of Fisheries, Wildlife and Environmental Law Enforcement at

(617) 727­3151.

TREATMENT OF WOUNDS AND IMMUNIZATIONS

The essential components of rabies post exposure prophylaxis are wound treat ment and, for previously unvaccinated

persons, the administration of bot h RIG and vaccine.  Persons who have been bitt en by animals suspect ed or proven

to be rabid should begin post exposure prophylaxis immediately.  Incubation periods of great er than 1 year have been

report ed in humans.  Thus, when a document ed or likely exposur e has occurred, post exposur e prophylaxis is

indicated regardless of the lengt h of the delay, provided the clinical signs of rabies are not present.

In 1977, the World Health Organization recommended a regimen of RIG and six doses of HDCV over a 90­day

period.  This recommendation was based on studies in Ger many and Iran.  When used this way, the vaccine was

found to be safe and effective in prot ect ing persons bitt en by animals proven to be rabid and induced an excellent

antibody response in all recipients.  Studies conduct ed in the Unit ed States by CDC have document ed that a regimen

of one dose of RIG and five doses of HDCV over a 28­day period was safe and induced an excellent ant ibody

response in all recipients.  Clinical trials wit h RVA and PCEC have demonstrated immunogenicity equivalent to that

of HDCV.

Treat ment of Wounds

Immediat e and thorough washing of all bit e wounds and scratches with soap and water and a virucidal agent, such as

povidone­iodine solut ion irrigation, are important measures for prevent ing rabies.  In studies of animals, thorough

wound cleansing alone wit hout other post exposure prophylaxis has been shown to reduce markedly the likelihood of

rabies.  Tetanus prophylaxis and measures to control bacterial infection also should be administ er ed as indicat ed.

The decision t o suture large wounds should take into account cosmet ic factors and the pot ential for bacterial

infections.  Prophylactic antibiot ics should be administ er ed as indicated.

Immunization

Postexposure ant irabies vaccination should always include administration of bot h passive antibody and vaccine,

with t he except ion of persons who have previously received complet e vaccination regimens (pr eexposure or

post exposur e) wit h a cell culture vaccine or persons who have been vaccinated wit h ot her types of vaccines and

have had document ed rabies antibody tit ers.  These persons should receive only vaccine (see Post exposure Therapy

for Previously Vaccinat ed Persons).  The combination of RIG and vaccine is recommended for both bit e and non­

bit e exposur es (see Rationale for Treatment ), regardless of the int erval bet ween exposure and initiation of treatment.

Human Rabies Immune Globulin Use

HRIG is administ ered only once (i.e., at the beginning of antirabies prophylaxis) to previously unvaccinated persons

to provide immediat e antibodies unt il the patient responds to HDCV, RVA, or PCEC by actively producing

antibodies.  If HRIG was not administ er ed when vaccination was begun, it can be administ ered through the sevent h

day after the administration of the first dose of vaccine.  Beyond t he sevent h day, HRIG is not indicated since an

antibody response to cell cultur e vaccine is presumed t o have occurred.  Because HRIG can partially suppress active

product ion of antibody, no more than the recommended dose should be administer ed.  The recommended dose of

human HRIG is 20 IU/kg body weight.  This for mula is applicable to all age groups, including childr en.  If

anatomically feasible, the full dose of HRIG should be thoroughly infiltrated in the area around and int o the wounds.

Any remaining volume should be inject ed intramuscularly at a site distant from vaccine administration.  This change

in the recommendat ions for HRIG administration is based on reports of rare failur es of post exposure prophylaxis

when smaller amounts of HRIG wer e infiltrated at the exposure sit es.  HRIG should never be administ ered in the

same syringe or in the same anatomical sit e as vaccine.

Vaccine Use

All rabies vaccine used in the Unit ed States are killed cell culture­derived vaccines.  Human Diploid cell vaccine

(HCDV), grown in human fiberblasts, is inactivated wit h beta­propriolactone and ultra­filtration and contains

neomycine.  It is effect ive if given wit h HRIG prompt ly following exposure.  The dose is 1cc (2.5 IU) IM,

regardless of age and weight.  Adults and children should receive HDCV in the deltoid area and infants in the

anterolat eral thigh.

Rabies Vaccine Adsorbed (RVA) is anot her rabies vaccine licensed in the U.S.   It is manufactured and distributed

by BioPort Corporation.  At the present time, BioPort is not manufacturing or distributing RVA.  RVA is produced

from virus grown in fetal rhesus lung diploid cells concentrated by absorption or aluminum phosphate. RVA is

administ er ed IM as described for HDCV.

A purified chick embryo cell (PCEC) vaccine is anot her vaccine licensed in the U. S.   It became available in the

U.S. in the fall of 1997. It is manufactured and distributed by Chiron Corporation.  It is prepared from fixed rabies

virus strain Flury LEP grown in primary cultures of chicken fibroblasts. The virus is inactivated wit h beta­

proprionolact one and further processed by zonal centrifugation in a sucrose densit y gradient.  It is for mulat ed for IM

administration only.  PCEC is available in a single­dose vial containing lyophilized vaccine t hat is reconstitut ed in

the vial wit h the accompanying diluent, to a final volume of 1.0 ml just before administration.

Three rabies vaccines are currently available in the United States (Table 1); any one of the t hree can be administer ed

in conjunct ion with RIG at the beginning of post exposure therapy.  A regimen of five 1­mL doses of HDCV, RVA,

or PCEC should be administ er ed intramuscularly.  The first dose of the five­dose course should be administ er ed as

soon as possible after exposure.  Addit ional doses should be administ er ed on days 3, 7, 14, and 28 after the first

vaccination.  For adults, the vaccination should always be administ ered IM in the deltoid area.  For childr en, the

anterolat eral aspect of the thigh is also acceptable.  The glut eal area should never be used for HDCV, RVA, or

PCEC inject ions because administration of HDCV in this area results in lower neutralizing antibody tit ers.

TABLE 1. Rabies biologics ­­ United States, 1999

Human rabies vaccine Product name                        Manufacturer

Human diploid cell vaccine Pasteur­Merrieux Serum et Vaccins,

(HFCV) Connaught Laboratories, Inc.

Intramuscular Imovax Rabies Phone:  (800) VACCINE (822­2463)

Intradermal Imovax Rabies I.D.

Rabies vaccine adsorbed Rabies Vaccine BioPort Corporation

(RVA) Adsorbed (RVA) Phone: (517) 335­8120

Technical Questions:

Intramuscular (517) 327­1500

Purified chick embryo cell RabAvert Chiron Corporation

vaccine (PCEC) Phone: CHIRON (800) 244­7668

Intramuscular

_______________________________________________________________________________________

Rabies immune globulin (RIG) Imogam Rabies­HT Pasteur­Merrieux Serum et Vaccines,

Connaught Laboratories, Inc.

Phone: (800) VACCINE (822­2463)

Treat ment Outside the United States

U.S. citizens who are exposed to rabies while traveling outside the Unit ed States in countries wher e rabies is

enzoot ic might sometimes receive post exposure therapy wit h regimens or biologics that are not used in the Unit ed

States (See Table 6 below).  This infor mation is provided to familiarize physicians wit h some of the regimens used

mor e widely abroad. The regimens described in the refer ences in t his report have not been submitt ed for approval

by the FDA for use in the Unit ed States.  If postexposure prophylaxis is begun outside t he Unit ed States using one of

these regimens or biologics of nerve tissue origin, it might be necessary to provide additional therapy when t he

patient reaches the Unit ed States.  State or local healt h departments should be contacted for specific advice in such

cases.  If titers are obtained, specimens collect ed 2­4 weeks aft er preexposure or postexposure prophylaxis should

complet ely neutralize challenge virus at a 1:5 serum dilution by t he RFFIT.

Purified equine rabies immune globulin (ERIG) has been used effectively in developing countries wher e RIG might

not have been available.  The incidence of adverse reactions has been low (0.8%­6.0%), and most of those t hat

occurred wer e minor.  In addition, unpurified ant irabies serum of equine origin might still be used in some countries

wher e neit her RIG nor ERIG are available.  The use of this antirabies serum is associated wit h higher rates of

serious adverse reactions, including anaphylaxis.

Although no post exposur e vaccine failures have occurred in the Unit ed States since cell culture vaccines have been

routinely used, failures have occurred abroad when some deviation was made from t he recommended post exposure

treatment protocol or when less than the currently recommended amount of antirabies sera was administer ed.

Specifically, patients who contracted rabies after postexposure prophylaxis did not have their wounds cleansed wit h

soap and wat er, did not receive their rabies vaccine injections in the delt oid area (i.e., vaccine was administ er ed in

the glut eal area), or did not receive RIG around the wound sit e.

Vaccines and Immune Globulins Used in Other Countries

Many developing countries use inactivat ed nerve t issue vaccines made from t he brains of adult animals or suckling

mice.  Nerve tissue vaccine (NTV) is reported to induce neuroparalytic react ions among approximat ely 1 per 200 to

1 per 2,000 persons vaccinated; suckling mouse brain vaccine (SMBV) causes reactions in approximately 1 per

8,000 persons vaccinated.  The vaccines HDCV, PCEC, PDEV, and purified vero cell rabies vaccine (PVRV) (See

Table 6. below) are cell cultur e­derived and not of nerve tissue origin.  In addition, unpurified antirabies serum of

equine origin might still be used in some countries where neit her RIG nor ERIG are available.  The use of this

antirabies serum is associated with higher rates of serious adverse reactions, including anaphylaxis.

Table 6. Cell cultur e rabies vaccined widely available outside t he Unit ed States

Purified chick embryo cell vaccine (PCEC) Rabipur

Purified ver ocell rabies vaccine (PVRV) Ver orab

Imovax­Rabies ver o

TRC Verorab

Human diploid cell vaccine (HDCV) Rabivac

Puirfied duck embryo vaccine (PDEV) Lyssavac

_______________________________________________________________

VACCINATION AND SEROLOGIC TESTING

Serologic Response Shortly After Vaccination

All persons t ested during several CDC studies 2­4 weeks after complet ion of preexposur e and post exposur e rabies

prophylaxis in accordance wit h ACIP guidelines have demonstrated an antibody r esponse to rabies.  Therefore,

serum samples from patients completing preexposur e or postexposur e prophylaxis do not need t o be t est ed to

document ser oconversion unless the person is immunosuppressed (see Precautions and Contraindications).  If tit ers

are obtained, specimens collect ed 2­4 weeks after preexposure or postexposure prophylaxis should complet ely

neutralize challenge virus at a 1:5 serum dilut ion by the RFFIT.  In animal studies, neutralizing ant ibody tit ers have

been shown to be imperfect markers of prot ect ion.  Antibody tit ers will vary wit h time since t he last vaccination.

Differ ences among laboratories that test blood samples also can influence t he results.

Cell culture vaccines have been used effectively wit h RIG or ERIG worldwide t o treat persons bitt en by various

rabid animals.  Worldwide, the World Healt h Organization est imat es that 10­12 million persons are started on

post exposur e therapy annually.  An estimat ed 16,000­39,000 persons in the Unit ed States receive a full post exposure

course wit h HDCV each year.  When post exposur e prophylaxis has been properly administ er ed, no treat ment

failur es have occurred in the Unit ed States.

Serologic Response and Preexposure Booster Doses of Vaccine

Although antibody levels do not define a person’s immune status, they are a marker of cont inuing immune response.

To ensure the continuit y of an immune r esponse, tit ers should be checked periodically, with boost er doses

administ er ed as needed.  Two years after primary preexposure vaccination, a 1:5 serum dilut ion will neutralize

challenge virus complet ely (by the RFFIT) among 93%­98% of persons who received the t hr ee­dose preexposure

series intramuscularly and 83%­95% of persons who received t he thr ee­dose series intrader mally.  If the tit er falls

below the minimum acceptable antibody level, a preexposure boost er dose of vaccine is recommended for a person

at continuous or frequent risk for exposure to rabies (See Attachment 4 PDF).  The following guidelines are

recommended for det er mining when serum testing should be perfor med aft er primary preexposure vaccination:

A person in the continuous­risk category (See Attachment 4 PDF) should have a serum sample t est ed for rabies

antibody ever y 6 mont hs.

A person in the fr equent ­risk cat egor y (See Attachment  4 PDF) should have a serum sample t est ed for rabies

antibody ever y 2 years.

State or local health departments can provide the names and addr esses of laboratories perfor ming rabies serologic

testing.

ADVERSE REACTIONS HDCV, RVA, and PCEC

Reactions after vaccination wit h HDCV, RVA, and PCEC are less serious and less common than with previously

available vaccines.  In previous studies wit h HDCV, local reactions (e. g., pain, eryt hema, and swelling or itching at

the inject ion sit e) have been reported among 30%­74% of recipients.  Systemic reactions (e.g., headache, nausea,

abdominal pain, muscle aches, and dizziness) have been reported among 5%­40% of recipients.  Three cases of

neurologic illness resembling Guillain­Barre syndrome that resolved without sequelae in 12 weeks have been

report ed.  In addition, other central and peripheral ner vous syst em disorders have been t emporally associat ed with

HDCV vaccine, but a causal relationship has not been established in these rare reports.

An immune complex­like reaction occurred among approximat ely 6% of persons who received boost er doses of

HDCV 2­21 days after administration of the boost er dose.  The patients developed generalized urticaria, somet imes

accompanied by arthralgia, arthritis, angioedema, nausea, vomit ing, fever, and malaise.  In no cases have these

reactions been life thr eatening.  This reaction occurred less frequent ly among persons receiving primary vaccination.

The reactions have been associat ed wit h the presence of betapropiolact one­alt er ed human albumin in the HDCV and

the development of immunoglobulin E (IgE) ant ibodies to this aller gen.

Human Rabies Immune Globulin

Local pain and low­grade fever might follow r eceipt of HRIG. Although not reported specifically for HRIG,

angioneurot ic edema, nephrot ic syndrome, and anaphylaxis have been r eported after injection of immune globulin

(IG), a product similar in biochemical composition but without antirabies activit y.  These react ions occur so rarely

that a causal relationship bet ween IG and these r eactions has not been established.

Bot h for mulations of RIG, BayRabTM and Imogam Rabies­HT, undergo multiple viral clearance procedur es during

preparation.  Ther e is no evidence t hat any viruses have ever been transmitt ed by commercially available HRIG in

the Unit ed States.

Management of Adverse Reactions

Once initiated, rabies prophylaxis should not be int errupted or discontinued because of local or mild syst emic

adverse reactions to rabies vaccine.  Usually, such reactions can be successfully managed with ant iinflammat ory and

antipyret ic agents, such as ibuprofen or acetaminophen.   When a person wit h a history of serious hypersensitivity to

rabies vaccine must be revaccinated, antihistamines can be administ er ed.  Epinephrine should be readily available to

count eract anaphylactic reactions, and the person should be observed carefully immediat ely after vaccination.

Although serious syst emic, anaphylactic, or neur oparalytic reactions are rare during and after the administration of

rabies vaccines, such reactions pose a serious dilemma for the patient and the attending physician.  A patient’s risk

of acquiring rabies must be carefully consider ed befor e deciding to discontinue vaccination.  Advice and assistance

on the management of serious adverse reactions for persons receiving rabies vaccines may be sought from the state

healt h department or CDC.

All serious syst emic, neuroparalytic, or anaphylactic reactions should be reported to t he Vaccine Adverse Event

Reporting Syst em (VAERS) via a 24­hour toll­free t elephone number ({800} 822­7967).

PRECAUTIONS AND CONTRAINDICATIONS

Immunosuppression

Corticost er oids, other immunosuppressive agents, antimalarials, and immunosuppressive illnesses can int erfere with

the development of active immunity after vaccination.  For persons wit h immunosuppression, preexposur e

prophylaxis should be administ er ed wit h the awareness that the immune response might be inadequate (see Primary

or Preexposure Vaccination).  Patients who are immunosuppressed by disease or medications should postpone

preexposure vaccinations and consider avoiding activities for which rabies preexposur e prophylaxis is indicated.

When t his course is not possible, immunosuppressed persons who are at risk for rabies should be vaccinat ed by the

IM route and their antibody titers checked.  Failure to ser oconvert after the third dose should be managed in

consultation wit h appropriate public health officials (see Preexposure Vaccination and Serologic Testing).

Immunosuppressive agents should not be administ ered during post exposure therapy unless essential for the

treatment of ot her conditions.  When post exposur e prophylaxis is administ er ed to an immunosuppressed person, it is

especially important that a serum sample be t est ed for rabies antibody to ensure that an acceptable antibody response

has developed.

Pregnancy

Because of the pot ential consequences of inadequately treated rabies exposure, and because ther e is no indication

that fetal abnor malities have been associated wit h rabies vaccination, pregnancy is not consider ed a contraindication

to post exposure prophylaxis. If the risk of exposur e to rabies is substantial, preexposur e prophylaxis might also be

indicated during pregnancy.

Cheryl Barbanel, MD, MBA, MPH, FACOEM Page 14

Allergies

Persons who have a history of serious hypersensitivit y to rabies vaccine should be revaccinat ed with caution (see

Management of Adverse React ions)

3. IMPLEMENTATION

3.1 Complet ion of a vaccination series for the rabies virus and documentation of current and adequat e

immunity to rabies virus is requir ed for all individuals ent ering spaces or rooms in which rabies infect ed

animals are present, and for all individuals whose job duties include anticipated contact wit h wild

animals known to carry the rabies virus.

3.2 All principal invest igators using the rabies virus must enroll all personnel manipulating the rabies virus

in this Rabies Protection Program.  Those individuals with pot ential exposure to animals which are

rabies infect ed or which belong to species known to carry rabies virus are offer ed rabies prot ect ion

upon enr ollment in the Bost on University Animal Exposure Surveillance Program.  It is the

responsibility of the PI and the individual to contact the Occupational Health Program to obtain ser vices

when pot ential exposure to rabies is anticipat ed and to maintain their currency with t he medical

evaluation of t heir titer status as defined above. See section 3.5 below for int er national medical travel

arrangements.

3.3 Biosafet y Level 2 practices, containment equipment and facilities are requir ed for all activit ies

involving the use or manipulation of rabies virus or rabies infect ed animals (ABSL­2).

3.4 All laboratories utilizing rabies virus and all ABSL­2 animal housing areas utilizing rabies virus are

inspect ed by the Office of Environmental Healt h and Safet y to verify appropriate containment and

work practices.  Addit ional primary containment, personnel precautions and personal prot ective

equipment, such as those described for Biosafety Level 3, may be indicated for activit ies wit h a high

pot ential for droplet and aerosol production and for activities involving product ion quantit ies or high

concentrations of the rabies virus.

3.5 Travel to for eign countries wit h pot ent ial exposur e to rabies including field biology work or bat

research must include identification of health care facilities and an understanding or the requirements to

access medical resources in the location or nearest resources for post­exposure treat ment and other

medical issues that may occur.  These arrangements must be ident ified prior to arrival.  Contact

Int ernational SOS by calling collect 215­245­4707 when you are outside the U.S. Ask to speak wit h the nurse.

Please ident ify a source for postexposure prophylaxis and care for ot her medical issues.  This is a 24­hour a day program.

3.6 The Bost on University Rabies Protect ion Program is designed t o reflect full compliance wit h the

recommendations of t he Advisory Committ ee on Immunization Practices (ACIP) in the document

Human Rabies Prevention, published by t he Cent ers of Disease Control in the Morbidit y and Mortality

Weekly Report on January 8, 1999 (Volume 48, No. RR­1). See Refer ences for this document by

clinking on link list ed at end of this document.

See Refer ences for Infor mation on Biosafet y Levels and Animal Biosafet y Levels, and Personal

Protect ive Equipment.

Boston University

Human Diploid­Cell Rabies Vaccine

I understand t hat due t o my occupational exposur e t o pot entially infectious mat erial and/or animals, I

may be at risk of gett ing a rabies infect ion.  The purpose of the Human Diploid­Cell Rabies vaccine

(HDCV) is to provide immunit y to t he rabies virus.  The vaccination series consists of three (3)

inject ions.  The inject ions are given on days 0, 7 and 21 or 28.

For persons at continuous risk of rabies exposure (i. e. persons working wit h rabies virus in research

environment) a blood sample will be t est ed for rabies antibody tit ers every 6 mont hs.  If the serum tit er

is not adequat e, a boost er injection of HDCV vaccine will be r equir ed.  For those who are fr equentl y

exposed to the rabies virus (i. e. vet erinarians and staff handling wild animal species known t o harbor

rabies) a blood sample will be t est ed for rabies ant ibody t it ers ever y 2 years and a boost er injection of

HDCV vaccine will be given if necessary.  Employees in these two groups are required to under go

vaccination, which is offer ed free of charge at Employee Healt h Services.

Vet erinarians and staff who handle purpose­br ed or post­quarantine wild animals t hat have not been

infect ed wit h rabies virus, or staff that handle animals not known t o harbor rabies virus are offer ed

rabies vaccination.  Any individual in these cat egories who elects t o be vaccinat ed is not r equir ed t o

have ant ibody tit ers or boost er vaccination.

The vaccine has the pot ential to produce certain side effects including but not limit ed to the following:

inject ion sit e sor eness, redness, or itching; headache, fatigue or dizziness; nausea, vomiting, abdominal

pain; arthralgias (aching joints), fever and malaise.  The incidence of serious side effects from t he

vaccine is less t han one percent (1%), wher eas the outcome aft er a rabies infection causing

encephalomyelit is (swelling and inflammation of the brain and spinal cord) is al ways fatal.  Pre­

exposure vaccination of immunosuppressed persons is not recommended.

Name: ____________________________________________ SSN/ID: __________________

Boston University

Consent for Rabies Vaccination

The risks and benefits of receiving the Human Diploid­cell Rabies Vaccine (HDCV) and t he risks of

acquiring rabies from an occupational exposur e have been explained t o me.  I acknowledge t hat no

guarantees have been made t o me r egarding the effectiveness of the vaccine or the absence of adverse

reactions to the vaccine.  I voluntarily give my consent to receive the HDCV vaccine.

______________________________________________              _________________________

Signature                                                                                                     Date

Human Diploid­Cell Rabies Vaccine (HDCV) DECLINATION

I understand t hat due t o my occupational exposure t o pot entially infectious mat erials and/or animals, I

may be at risk of acquiring rabies infection.  I have been given t he opportunit y t o be vaccinat ed wit h

HDCV vaccine at no charge t o myself.  However, I decline t he HDCV vaccination at this time.  I

understand t hat by declining this vaccine, I will be excluded from t hose projects that involve working

with t he rabies virus, or from tasks, which are included in the Continuous Risk Category or the Frequent

Risk Category. I further understand t hat if I sustain a pot ential exposur e t o rabies t hat I must seek

immediat e medical care even if I have been vaccinated to receive post­exposure treatment.

______________________________________________              _________________________

Signature                                                                                                     Date

PRIOR Human Diploid­Cell Rabies Vaccine (HDCV)

(Complete if applicable; documentation must be provided)

I have previously received the rabies vaccination in (indicate year received)

By (indicate

doctor/clinic).

______________________________________________              _________________________

Signature                                                                                                     Date

FOR CLINIC USE ONLY

Date Administered

Vaccine Manufacturer

Lot Number

Expiration Date

Injection Site

Signature Date

References:

Attachment 1.  Guide To Rabies Post–Exposure Evaluation and Management

PDF

Attachment 2.  Management of Human Exposure to Suspect ed Rabid Animals

PDF

Attachment 3.  Rabies Post­Exposure Prophylaxis Schedule

PDF

Attachment 4.  Rabies Pre–Exposur e Prophylaxis Guide

PDF

Attachment 5.  Biosafety in Microbiological and Biomedical Laboratories, 4th Edition

Laboratory Biosafet y Levels

“Laboratory

Biosafety Levels” “BSL Table III”

Sect ion III, Table 1. Summary of Recommended Biosafety Levels for Infect ious Agents

http:// www.cdc.gov/ od/ohs/biosfty/bmbl4/bmbl4s3t.htm

Attachment 6.  Biosafety in Microbiological and Biomedical Laboratories, 4th Edition

Vert ebrate Animal Biosafety Level Criteria

“Vertebrate Animal

Biosafety Level Criteria” “Animal Vertebrate BSL Table IV”

Sect ion IV, Table 1. Summary of Biosafet y Levels for Act ivities in Which Experimentally or

Naturally Infect ed Vert ebrate Animals Are Used

http://www.cdc.gov/ od/ohs/biosfty/bmbl4/bmbl4s4t.ht m

BMBL:  Agents Summary Statements­ Viral Agents:  Rabies Virus

Biosafet y in Microbiological and Biomedical Laboratories 4 th Edit ion pp 167–168. 5/99

http:// www.cdc.gov/ od/ohs/biosfty/bmbl4/bmbl4toc.ht m pp 170­171.

Human Rabies Prevention ­ Unit ed States, 1999 Recommendat ions of the Advisory Committ ee on

Immunization Practices (ACIP) ht ml

http://www.cdc.gov/ mmwr/PDF/rr/rr4801.pdf

Public Healt h Fact Sheet on Rabies (PDF) / MS Word version

Rabies and Bats, FAQ for Physicians

Prevent ion of Rabies in Humans (PDF)

Hanlon, CA, Rupprecht CE,  Health Precautions for Bat Workers

(In­press wit h permission) See page 5­6 for discussion on personal protect ive equipment.

“Health Precautions

for Bat Workers”

Messenger, S.L., C.E. Rupprecht, and J.S. Smith. 2003. Bats, emerging virus infect ions, and the rabies

paradigm. Pp. 622­679. In: Bat Ecology (T.H. Kunz and M.B. Fenton, eds.). University of Chicago Press,

Chicago.

Management of Rabies in Humans

http:// www.cdc.gov/ ncidod/ dvrd/rabies/professional/publications/ miscellaneous/ management.pdf

Additional Information on Rabies from The Commonwealth of Massachusetts Department of Public

Health

I.  Rabies Control Plan Massachusetts 2003

http:// www.state.ma.us/dph/cdc/ epii/rabies/controlplan/rabiescp.ht m

Cover Page, Index and List of Attachments

PDF

Chapter 1.  General Infor mation

PDF

Chapter 2.  Human Exposure 2003

PDF

Chapter 3.  Domestic Animal; Issues

PDF

Chapter 4.  Wild Animal Issues

PDF

Chapter 5.  Cape Cod Oral Rabies Vaccination Program

PDF

Attachment 1.  Guide To Rabies Post–Exposure Evaluation and Management

PDF

Attachment 2.  Management of Human Exposure to Suspect ed Rabid Animals

PDF

Attachment 3.  Rabies Post­Exposure Prophylaxis Schedule

PDF

Attachment 4.  Rabies Pre­Exposure Prophylaxis Guide

PDF

Attachment 5.  Advisory Committ ee on Immunization Practices Statement on Rabies Prevent ion and

CDC Rabies Websit e link.

PDF

Attachment 6.  Recommendat ion for Petting Zoos, Petting Farms, Animal Fairs, and Other Events

and Exhibits wher e Contact Bet ween t he Public and Animals is Permitt ed

PDF

Attachment 7. Notice of Possible Exposure to Rabies and Quarantine Order

PDF Sample Notice of Possible Exposure to Rabies and Quarantine Or der

PDF Definitions

PDF Sample Order of Quarantine

Attachment 8.  Rabies Protocol:  Management of Dogs and Cats Exposed to Wildlife

PDF

Attachment 9.  Rabies Protocol:  Management of Dogs and Cats Exposed to Other Domestic

Animals

PDF

Attachment 10.  Rabies Protocol: Management of Dogs and Cats Which Expose Humans

PDF

Attachment 11.  MDPH, SLI, Virology Laboratory’s Guidelines for Submission of Specimens

for Rabies Testing

PDF

Attachment 12.  Useful Rabies Contact Information­ Telephone Numbers and Web Resources

(Vaccine Contacts/Emergency Infor mation)

PDF

Attachment 13.  Compendium of Animal Rabies Prevention and Control

PDF

II. Commonwealth of Massachusetts Department of Public Health Rabies Website

Massachusetts Department of Public Health Rabies Infor mation

http:// www.state.ma.us/dph/cdc/ epii/rabies/rabies.ht m

General Information on Rabies

Public Healt h Fact Sheet on Rabies (PDF) / MS Word version

Bats and Rabies, A Public Health Guide – Cent ers for Disease Control (PDF) / MS Word version

Risk of Rabies Associated with Differ ent Animals

Other Agencies Involved in Rabies Control

Rabies Pathogenesis and 10–Day Animal Quarantine

Two­sided Card (PDF 172k)

Four­sided Card(PDF 209k)

A Summary of Rabies in Massachusetts, 1992­2002 (PDF 107k) /MS Word Version

This document summarizes the number of animals submitted and tested for rabies in

Massachusetts by species, year, month and county for a 10 year period.

Recommendations

Animal Exposure Protocol for Camps

Information for Local Boards of Health

2003 Rabies Control Plan for Cities and Towns

Information for Healthcare Providers

Management of Human Exposure to Suspect Rabid Animals (PDF) /MS Word version

Prevention of Rabies in Humans (PDF)

Rabies and Bats, FAQ for Physicians

Recommendations for Pre­Exposure Prophylaxis / (PDF version 86k)

Rabies Post­Exposure Prophylaxis Schedule

Information for Veterinarians and Animal Control Officers

Management of Dogs and Cats Exposed to Wildlife

Management of Dogs and Cats Exposed to Other Domestic Animals

Management of Dogs and Cats Which Bite Humans

Massachusetts Rabies Immunization Program for Dogs, Cats, and Ferrets

Related Links

Massachusetts Division of Fisheries, Wildlife, and Environmental Law Enforcement

Massachusetts Department of Food and Agriculture, Bureau of Animal Health

US Department of Agriculture, Wildlife Services

Centers for Disease Control Rabies Homepage

Centers for Disease Control Rabies Kids’ Website