Algoma Public Health

Rabies

In humans, rabies is a fatal viral infection that rarely occurs in Canada.

All mammal bites must be reported to public health, regardless of the risk of rabies.

Exposure occurs when a human is bitten or scratched by an infected animal, with bats being the most common reservoir and the highest risk of exposure. Rabies is prevalent in bats, and all bats should be treated as potentially rabid. Rabies has also been detected in land mammals in Ontario and is most commonly seen in skunks, foxes, and raccoons. Imported mammalian pets may be a risk for rabies depending on their country of origin.

The usual incubation period may vary from several days to years (most commonly three to eight weeks). Once clinical signs of rabies appear, the disease is nearly always fatal. Health Care Providers must assess, manage, and report.

Your Role as the Provider

The steps to report a possible rabies exposure and receive PEP for administration are explained in detail under the additional information section but can be summarized below:

The healthcare provider must assess the wound and clean/treat accordingly. The routine process for possible rabies exposure should be followed:
- If it is a mammal bite, do a risk assessment to determine the need for rabies Post-Exposure Prophylaxis (rPEP).
- Report the potential rabies exposure to Algoma Public Health using our reporting form
- To request rPEP call 705-759-5286 (after hours: 705-759-5416). When requesting release of rPEP, please include information needed for the risk assessment and treatment including weight, immune status, a description of any wounds, species of animal, type of exposure, and likelihood that the animal was provoked.
A Public health inspector (PHI) will contact the on-call public health physician for release of rPEP.
- If the need for rPEP is unclear, the public health physician will work with the PHI or the healthcare provider to clarify risk.
If rPEP is released, a PHI will deliver it to the clinic or emergency department for the treating provider to administer. Delivery is available 24 hours per day.
- Algoma Public Health does not do Day 0 rPEP administration and is not set up for wound management.
- The treating provider is responsible for the full series of rPEP administration. In some circumstances, we may provide follow-up doses of vaccine at Algoma Public Health offices, available only during business hours.

Additional Information for Providers

Assess

Animals in Canada that are reported as positive for rabies most often include bats and wild terrestrial carnivores (e.g., racoons, skunks, and foxes). Refer to the Public Health Ontario guidance on how to assess rabies exposure (algorithms for bats begins on page 7 of the document). When completing a risk assessment, consider the species. Exposures warranting rabies post-exposure prophylaxis (rPEP) include:

any direct contact with a bat (even if signs of a wound or puncture are not present) and should be considered for bite (penetration of the skin by teeth)
and non-bite exposures (scratches, abrasions, or cuts of the skin or mucous membrane) from other mammals.

Animal behaviour must also be considered during the risk assessment. For many animals, especially wild animals, biting can be considered normal behaviour when provoked. The risk of rabies is therefore considered higher in situations where an attack is unprovoked. If the animal is available to be observed or tested, this will also impact the client's risk of exposure to the rabies virus. Exposures occurring in other jurisdictions (i.e., bites on returning travelers) may carry varying risks of rabies exposure.

All animal bites and other possible rabies exposures must be reported to Algoma Public Health by completing a Rabies Control Investigation - Hospital Physician Report and faxing it to 705-541-7346. This can be If rabies post-exposure prophylaxis may be required, you must contact the on-call public health inspector. This can be done when reporting the bite to a Public Health Inspector (PHI).

Vaccine and RIG must be released by Algoma Public Health.

Manage

When indicated, rPEP should be given promptly. The process for rPEP includes:

Step 1: Wound Care

Post-exposure management includes immediate and thorough flushing of the wound to its depth with soap and water for approximately 15 minutes. Application of viricidal agents may be considered. Suturing the wound should be avoided when possible, and tetanus prophylaxis and antibiotics may be considered appropriate. If indicated based on risk assessment, rabies immunoglobulin should be administered. Rabies immunoglobulin dosing is weight-based and is most effective when infiltrated at the site of the wound (with as much as safely possible) and the remaining dose being injected IM, using a separate needle and syringe.

Report

Rabies is classified as a disease of public health significance and all cases involving a mammal bite or contact with a mammal that is conducive to the potential transmission of rabies must be reported to APH (as per Regulation 557 under the Health Protection and promotion Act). The rPEP release form must be completed and faxed to Algoma Public Health. Reporting can be done by calling APH at 705-759-5286 Monday to Friday from 8:30 am – 4:30 pm or after hours at 705-759-5416 or fax us at 705-541-7346.

Step 2: Administration of Vaccine

Rabies vaccine is typically given in a 4-dose series (on days 0,3,7, and 14) in immunocompetent patients. It should be given IM at a different anatomical site from where rabies immunoglobulin is given.

Vaccine Status	Day 0	Day 3	Day 7	Day 14	Day 28
NOT previously immunized against rabies and immunocompetent	Rabies vaccine and Rabies Immune Globulin	Rabies Vaccine	Rabies Vaccine	Rabies Vaccine	No further action required
NOT previously immunized against rabies and immunocompromised or on antimalarial drugs	Rabies vaccine and Rabies Immune Globulin	Rabies Vaccine	Rabies Vaccine	Rabies Vaccine	Rabies Vaccine
Previously immunized with a documented* complete course of rabies vaccine (HDCV/PCECV)	Rabies Vaccine	Rabies Vaccine	No further action required	No further action required	No further action required
Previously immunized with a complete course of rabies vaccine *without documentation*	Serology before administering: Rabies vaccine and Rabies Immune Globulin	Rabies Vaccine	If an acceptable concentration (0.5 IU/ml or greater) is demonstrated, the vaccine course may be discontinued, provided that at least two doses of vaccine have been given. Otherwise, administer the complete series based on patient immune state (see above).

NOTE: Do not discard unused vials of RabIg and/or rabies vaccine dose. Store in a refrigerator and contact APH for pick up.

**Documentation of complete immunization with other types of rabies vaccine, or with unapproved schedules of HDCV/PCECV rabies vaccine, with demonstration of acceptable serology requires consultation with an Algoma Public Health Medical Officer of Health.

Information related to the vaccine administration (dose, route of administration, and schedule) can be found in the Canadian Immunization Guide here.

Recommendations for the administration of Rabies Post-Exposure can be found here.

Step 3: Arrange follow-up for remaining vaccines with the primary care provider or with APH.

Arranging follow-up doses is the responsibility of the assessing provider (MD/NP), and the prophylaxis schedule must be followed closely to ensure adequate protection. In some circumstances we may provide follow-up doses of vaccine at Algoma Public Health offices, available only during business hours

Report