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.
Case Study:
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 18th of July. Saliva was later
found to be positive.
The patient’s neurologic status continued to deteriorate
leading to her death on the 20th 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
Specimen
Test
Results
Pituitary, Spinal cord
Rabies Virus
Positive
Liver, Spleen, Pancreas, Gallbladder
Rabies Virus
Negative
Kidney, Adrenal
Rabies Virus
Negative
Esophagus, Stomach
Rabies Virus
Negative
Muscle, Skin
Rabies Virus
Negative
Cervix, Uterus, Ovary, Fallopian Tube
Rabies Virus
Negative
Cortex, Paraventricle, Cerebellum,
Brain Stem, Spinal Cord, Hippocampus
Rabies Virus
Positive
Evaluation of Healthcare Workers Exposure
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
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 rabiesendemic 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…..
Important Websites:
 http://nj.gov/health/cd/documents/faq/rabies_faq.pdf
 http://www.cdc.gov/rabies/exposure
 www.uptodate.com
 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6051a2.htm
Questions?