Animal Bites and Other Potential Rabies Exposures 2
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 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 2 Garcia, VF. Animal bites and pasturella infections. Pediatrics 3 http: //www. cdc. gov/nchs/fastats/ervisits. htm Prev. Oct 2008; 14(5): 296 -301. in Review. 1997; 18: 127 -130.
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 § 64 -7 -3 and § 64 -7 -5 – 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 animal – Behavior of animal – Vaccination status of biting animal – Local rabies epidemiology
Case Management
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 Public Health Actions – Outcome of patient
Report received
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 Confine / Observe Management of animal Animal Dead Lost to Followup
Report received Verify victim info Verify exposure info Management of animal Confine / Observe Animal Dead Lost to Followup Cat/dog/ferret: 10 days from exposure date Livestock: 14 days from exposure date Others: confine/observe not appropriate
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 Followup
Report received Verify victim info Verify exposure info Confine / Observe Management of animal Animal Dead Lost to Followup Tested for rabies Not tested
Report received Verify victim info Verify exposure info Confine / Observe Management of animal Animal Dead Document Test Result: • Positive • Negative • Indeterminate Lost to Followup
Report received Verify victim info Verify exposure info Confine / Observe Management of animal Animal Dead Lost to Followup (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 üRIG date üVaccine 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) Variable Patient name Date of birth County of residence Gender Race Ethnicity Percent Complete 100% 99. 8% 97. 9% 56. 0% 42. 4%
Completeness of Exposure Fields (2009) Variable Exposure type Exposure date Exposure time of day Body location Exposure provoked Percent Complete 99. 8% 100. 0% 62. 7% 98. 2% 85. 9%
Completeness of Species Fields (2009) Variable Species involved Ownership (pet, stray or wild) Animal final outcome/status Breed (canine only) Vaccination history (pet only) Specimen submitted Specimen result (if submitted) Percent Complete 99. 9% 97. 4% 91. 7% 74. 4% 50. 7% 89. 1% 95. 5%
Completeness of Outcome Fields (2009) Variable Patient death Patient hospitalization PEP initiated PEP status Percent Complete 100. 0% 96. 2% 85. 8% 46. 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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