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4. RABIES AND OTHER LYSSAVIRUS INFECTIONS

Control Guideline

Last updated: 24 August 2012

1. The disease

Infectious agents
Rabies virus and Australian bat lyssavirus (ABLV) are both members of the Rhabdoviridae family, genus Lyssavirus. ABLV is closely related but not identical to the classical rabies virus. ¹

Reservoir
All mammals are susceptible to rabies and therefore are possible reservoirs. Dogs are the principal reservoir in developing countries and responsible for 99% of human infections. ² Other reservoirs and important vectors include wild and domestic Canidae, including dogs, foxes, coyotes, wolves and jackals; and bats, cats, monkeys, skunks, raccoons, and mongooses. Other mammals may rarely be infected. The animal population in Australia is currently free from classical rabies. However, evidence of ABLV infection has been documented in several species of flying foxes (also known as fruit bats) and insectivorous microbats. It is assumed that all Australian bat species have the potential to carry and transmit ABLV.

Mode of transmission
Rabies is transmitted by the virus-laden saliva of an infected animal introduced via a bite or scratch, or by contamination of mucous membranes or broken skin. Person-to-person transmission via saliva is extremely rare and has not been well documented. There have been rare reports of rabies transmission by transplantation of infected tissues/organs ^{3, 4} and via inhalation of virus-laden aerosol in laboratory settings. ^{5, 6} Aerosol transmission in humans has never been proven in the natural environment but remains theoretically possible based on animal experiments. ^{7, 8}

The only two known human cases of ABLV infection occurred in people who had been bitten by bats. It is assumed that the mode of transmission for ABLV is similar to that of rabies.

Incubation period
The incubation period for rabies is usually 3-8 weeks, rarely as short as a few days or as long as several years.¹ The length of the incubation period depends on many factors including wound severity, wound location in relation to nerve supply, proximity to the brain, size of inoculum of virus and the degree of protection provided by clothing and other host factors.¹ The incubation period for ABLV is less certain but is assumed to be similar to rabies; the two documented cases of ABLV infection had likely incubation periods of approximately 4 weeks and over 2 years, respectively.⁹

Infectious period
The infectious period for rabies has been described reliably only in dogs, cats and ferrets, in which communicability usually commences 3-7 days before onset of clinical signs and persists throughout the course of the illness.¹ The period of communicability of ABLV is not known.

Clinical presentation and outcome
Rabies is an almost invariably fatal, acute viral encephalomyelitis. Initial symptoms include fever and sensory changes (pain or paraesthesia) at the site of a preceding animal bite. Other reported prodromal symptoms include a sense of apprehension, headache and malaise. There are 2 clinical forms of rabies. Encephalitic or furious rabies presents in about two-thirds of cases, and is characterised by hyperactivity and aerophobia and/or hydrophobia followed by delirium with occasional convulsions. The second form, paralytic or dumb rabies, presents in about one-third of cases, with paralysis of limbs and respiratory muscles with sparing of consciousness.¹⁰ Phobic spasms may be absent in the paralytic form. Death from cardiac or respiratory failure occurs within a few days for furious rabies and within 1-2 weeks for the paralytic form of the disease. ^{1, 2} Based on the two known human cases of ABLV infection, it is assumed that infection with ABLV involves the same clinical features as rabies.

People at increased risk of disease
The risk of infection after the bite of a rabid animal can range from less than 1% to over 80%, presumably related to the size of inoculum, severity of bite, nerve density in the area of the bite, proximity of the bite to the central nervous system, vaccination status and immunocompetence.¹¹ People at increased risk of rabies/ABLV infection are those whose occupational, volunteering, or recreational activities put them at increased risk of exposure, i.e. being bitten or scratched by animals (including bats) in rabies-endemic countries or, in relation to risk of ABLV infection, by bats in Australia. In Australia, therefore, risk is greatest in those who holiday or work in countries in which rabies is endemic, and in those most likely to come into contact with bat species, including wildlife carers, wildlife officers, veterinarians and those who live in areas where bats are common.

Disease occurrence and public health significance
Australia is free from classical rabies. Only two imported human cases have been reported in Australia in travellers returned from endemic areas. Rabies is endemic in Asia (including Southeast Asia where large numbers of Australians travel), Africa, North and South America and parts of Europe. Worldwide, it is estimated that rabies is responsible for more than 50,000 deaths per year, almost all in rural areas of Asia and Africa, with the highest incidence in children under 15 years.¹² Rabies is estimated to have at least as much public health impact in tropical countries as dengue fever (when comparing disability-adjusted life years) and results in an estimated annual global financial burden of over US$ 1 billion. ^{12, 13} Most human deaths follow dog bites for which adequate post-exposure prophylaxis was not or could not be provided. Post-exposure prophylaxis initiated at an early stage using rabies vaccine in combination with rabies immunoglobulin may be 100% effective in preventing death. In Australia, rabies is subject to quarantine controls under the Commonwealth Quarantine Act 1908.The primary concern is the prevention of the introduction of rabies virus to local dog and wildlife populations.

ABLV is unique to Australia and was first identified in 1996 in an encephalitic black flying fox. Two human cases have been reported in Australia, in 1996 and 1998. Both cases developed fatal encephalitis after being bitten by bats. To date, virological and/or serological evidence of ABLV infection has been found in all four species of flying fox (megachiropterans) and at least seven genera of Australian insectivorous bats.¹⁴ Any Australian bat should be considered a potential carrier of the virus. The risk of human exposure to ABLV is related to the extent of human contact with Australian bats.

2. Routine prevention activities

Pre-exposure vaccination
Pre-exposure vaccination with rabies vaccine is recommended for people whose occupation (including volunteer work) or recreational activities place them at increased risk of being bitten or scratched by bats, as well as those who work in or travel to rabies-endemic countries, following a risk assessment. (WHO maintain maps of rabies-endemic areas: see www.who.int/rabies/en/). Current recommendations for pre-exposure vaccination include: bat handlers, veterinarians, wildlife officers, and others who come into direct contact with bats; laboratory personnel working with live lyssaviruses; expatriates and travellers (following a risk assessment) who will be spending time in rabies-endemic areas; and people working with mammals in rabies-endemic areas.^{15, 16}
Pre-exposure vaccination with rabies vaccine consists of 3 doses by intramuscular (IM) injection; with the second dose 7 days after the first and the third dose 21-28 days after the first dose. Booster doses are not required for anyone who has received 3 or more previous IM doses of rabies vaccine, if their only exposure risk is travelling to or living in a rabies endemic area.¹² Booster doses may be required if there is an ongoing occupational (including volunteer work) exposure risk, on the basis that there may be increased likelihood of an inapparent exposure occurring. An algorithm outlining the approach to booster doses is provided at Appendix 1. Consult the current edition of The Australian Immunisation Handbook if further information on vaccine administration and booster doses are required. See http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home

It is strongly recommended that the IM route be used for pre-exposure vaccination in Australia. Antibody titres at 14 days are lower and wane more rapidly after intradermal (ID) administration of rabies vaccine, and there may be a slower initial immune response following exposure to rabies virus.17, 18 As rabies vaccines are not licensed for intradermal use in Australia, any use of this method is the practitioner's own responsibility. In circumstances where the cost of IM vaccination is a significant barrier to a traveller, ID rabies pre-exposure vaccination, using a dose of 0.1 mL on days 0, 7 and 28, could be considered, provided that:

• it is given by those with not only expertise in, but also regular practice of, the ID technique
• it is not administered to anyone who is immunocompromised
• it is not administered to those taking either chloroquine or other antimalarials structurally related to chloroquine (e.g. mefloquine) at either the time of, or within a month following, vaccination
• any remaining vaccine is discarded at the end of the session during which the vial is opened (i.e. within 8 hours)
• the rabies antibody level is checked 14 to 21 days following completion of the pre-exposure course of ID vaccine.15

ID pre-exposure administration of rabies vaccine should not be used for pre-exposure prophylaxis for ABLV infection, due to lack of data on the protection provided.15

Handling bats
Only appropriately vaccinated and trained people should handle bats. Community members should not handle bats and should contact the nearest registered vaccinated wildlife carer (through a wildlife service or carer group), wildlife officer or veterinarian for assistance if a bat requires rescuing. If bats must be handled, safety precautions, such as wearing protective gloves and clothing, should be observed. Every effort should be made to avoid being bitten or scratched.

Travel advice
Travellers to rabies-endemic regions should be advised to avoid close contact with either wild or domestic mammals (especially dogs, cats, bats and monkeys), as well as what to do should they be bitten or scratched by an animal while abroad. This advice should include stressing the importance of obtaining as much written detail as possible on any post-exposure management provided overseas. Parents should ensure that their children are careful around animals as children are at optimal height for high-risk bites to the face and head. Rabies pre-exposure vaccination (or if appropriate, booster doses) should be advised pre-travel where indicated by a risk assessment, which should include ease of access to post-exposure prophylaxis (PEP) and likelihood of interaction with animals based on type of accommodation and planned activities.

Management of potential human exposure to rabies or ABLV (see algorithms in Appendices 2-3)

Definition of potential exposure
Any bite or scratch from, or mucous membrane or broken skin contact with the saliva or neural tissues of, a bat in Australia, or a wild or domestic mammal (including bats) in a rabies-endemic country. The latter includes Bali, Indonesia from August 2008 onwards.

If there are concerns about other potential exposures, expert advice should be sought.

Principles of post-exposure management
Post-exposure management is recommended for any person with a potential exposure. Post-exposure management comprises wound care and administration of a combination of rabies vaccine and human rabies immunoglobulin (HRIG), depending on exposure category and prior vaccination or antibody status. Post-exposure management should generally commence as soon as possible following potential exposure. If a traveller presents more than 10 days after being bitten or scratched by a dog or a cat in a rabies endemic country, and it can be reliably ascertained that the animal remains healthy, then post-exposure management is not required.

Bats involved in a potential ABLV exposure in Australia should be tested where possible, without placing others at risk of exposure. In such situations PEP can be delayed for 48 hours post-exposure to enable a result from the bat to be received. If results are not likely to be available within 48 hours of exposure then PEP should be commenced. If the bat tests negative, PEP is not required, and should be discontinued if already commenced.

Wound care
Immediate cleansing of the wound is an important measure for minimising transmission risk.>19 Animal studies have shown that immediate and thorough cleansing of the wound reduces the risk of infection.>20, 21All wounds should be washed thoroughly for approximately 5 minutes with soap and copious water, as soon as possible after the exposure. A virucidal antiseptic solution such as povidone-iodine or alcohol should be applied.>12 The wound should not be sutured unless unavoidable, and then should only occur after HRIG administration, where indicated.

WHO exposure categories 12 (see algorithms in Appendix 2-3)

Type of exposure	Description	Use of PEP
Category I	Touching or feeding animals, licks on intact skin	No prophylaxis is required
Category II	Nibbling of uncovered skin, minor scratches or abrasions without bleeding	Use rabies vaccine alone
Category III	Single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva from licks, licks on broken skin, exposures to bats	HRIG and rabies vaccine

Post-exposure prophylaxis for people not previously vaccinated
Potential rabies and ABLV exposures
Immunocompetent people should receive 4 doses of rabies vaccine by IM injection on days 0, 3, 7 and 14. A single dose of HRIG should also be given for category III exposures, regardless of time interval since exposure, except where more than seven days have elapsed after administration of the first vaccine dose.

Immunosuppression
Immunosuppressed people (whether through disease or treatment) should receive five doses of vaccine IM on days 0, 3, 7, 14 and 28, for both rabies and ABLV potential exposures. A single dose of HRIG should also be given for category III exposures, regardless of time interval since exposure, except where more than seven days have elapsed after administration of the first vaccine dose. A person who is immune suppressed should have rabies antibody titre checked 2 to 3 weeks after completion of the vaccine regimen. If the titre is <0.5 IU/ml a further dose of vaccine should be given and serology re-checked 2 to 3 weeks later. Where the titre remains suboptimal (<0.5 IU/mL) an infectious diseases expert should be consulted about the need for further doses.

Post-exposure prophylaxis for people previously vaccinated
People who have received three documented IM doses of an appropriate cell culture based rabies vaccine at any time in the past or who have documented rabies antibody titres ≥0.5 IU/ml ¹² (e.g. at any time subsequent to a course of ID pre-exposure vaccination), should receive 2 doses of vaccine IM on days 0 and 3. HRIG is not required. If vaccination status is uncertain, management should occur as for people not previously vaccinated.

Rabies vaccine use
For adults and children one year of age or older, the rabies vaccine should be administered into the deltoid area, as administration in other sites may result in reduced neutralising antibody titres. In infants under 12 months of age, administration into the anterolateral aspect of the thigh is recommended.

HRIG use
HRIG, where indicated, should be infiltrated at a dose of 20 IU/kg in and around the wound. It is imperative that as much HRIG as possible is given into the wound. It may be diluted if there are multiple wounds but as much as possible should go into the wound. The balance of any HRIG dose that cannot safely be infiltrated around the wound, or the whole HRIG dose in situations such as mucous membrane exposures (where there is no wound), should be given IM at a site distant (e.g. alternative deltoid or buttock muscle, depending on volume) to that where rabies vaccine is given.

HRIG is given to provide localised anti-rabies antibody protection while the person mounts an immune response to the rabies vaccine. HRIG should be administered with the first dose of rabies vaccine (day 0). If this is not possible, HRIG can be given up to day 7 following the first dose of vaccine, but it is not recommended from day 8 onwards as it may suppress the immune response to the vaccine.

Management of PEP in people who have begun prophylaxis overseas
The principle of management of PEP in people who have begun prophylaxis overseas is to continue the course if treatment commenced overseas with an appropriate cell culture derived vaccine. All cell culture based vaccines can be used interchangeably to complete a treatment course.12 HRIG should be given for category III exposures if RIG (whether equine or human) was not given and the person presents within 7 days of the first vaccine dose. If the person presents 8 days or more after the first dose of rabies vaccine then HRIG should not be administered.

A number of WHO endorsed rabies PEP schedules are used overseas. These include:

• Zagreb schedule (2 doses on day 0, single doses on days 7 and 21)
• Essen schedule (doses given on days 0, 3, 7, 14 and either 28 or 30)
• Modified Essen schedule (doses given on days 0, 3, 7 and 14)

The following table provides recommended courses of action for continuation of PEP in Australia, depending on the PEP received overseas:

Treatment (vaccine +/- RIG) administered overseas	Rabies vaccine schedule in Australia	Use of HRIG in Australia (Category III exposures only)
Unsure/unknown/poor documentation	Recommence course, starting from day 0.	Administer HRIG if within 7 days of the first dose of rabies vaccine. Do not administer if 8 days or more since first dose of vaccine.
Well documented, RIG (equine or human) given, plus vaccine given either IM or ID	Align with nearest due dose and resume schedule, adjusting for delay and administering vaccine IM (e.g. if a person had only day 0 vaccine dose (+ RIG) overseas, and presents 6 days later, give day 3 dose immediately, day 7 dose 4 days later and day 14 dose 7 days after that).	No HRIG needed
2 doses of rabies vaccine given IM on day 0, with no RIG	Give further 2 doses only, one on day 7 and one on day 14. If patient presents after day 7, consider that day as day 7.	Administer HRIG only if within 7 days of the 1st doses of rabies vaccine. Do not administer if 8 days or more since first dose of vaccine.
2 doses of rabies vaccine given IM on day 0, plus RIG (equine or human) administered at same time as the 1st doses.	Convert to the modified Essen schedule, with the 2 doses as equivalent to 1 dose (day 0). Give day 3 dose as soon as practicable, then complete with day 7 and day 14 doses.	No HRIG needed
Immune impaired, with vaccines administered ID.	Irrespective of number of doses administer a 5-dose schedule IM and check antibody titre (see 'Immunosuppression' p 6).	Administer HRIG if within 7 days of the first ID dose of rabies vaccine administered overseas. Do not administer if 8 days or more since first dose of vaccine.
Nerve tissue vaccine (NTV)	Recommence course, starting from day 0.	Administer HRIG if not already given, and within 7 days of first dose of NTV given overseas.

IM = intramuscular; ID = intradermal

Deviations from The Australian Immunisation Handbook advice
The use of four doses of rabies vaccine administered on days 0, 3, 7 and 14 (modified Essen schedule) for rabies and ABLV PEP for immunocompetent people has been recommended by the Australian Technical Advisory Group on Immunisation (ATAGI)¹⁶and will be included in the 10th Edition of the Handbook.

Other recommendations to be included in the 10th Edition of the Handbook include¹⁶:

• Recommendation of rabies pre-exposure vaccination (or if appropriate, booster doses) to travellers based on a risk assessment of access to PEP and likelihood of interaction with animals, rather than simply a month-long period of travel.
• More detailed recommendations for management of people who have commenced PEP overseas, as per the table above.

HRIG prioritisation in periods of shortage
Recurrent shortages of HRIG have occurred in Australia. From time to time, HRIG prioritisation measures may be implemented, at the recommendation of the Communicable Diseases Network Australia. These measures could include:

• Rounding down the dose when 0.5ml or less of a new ampoule is indicated to be injected in adults over 60kgs (e.g. 8.5 ml becomes 8 ml, requiring the use of four rather than five 2 ml ampoules of HRIG)
• Restricting the use of HRIG to potential exposures that have occurred within the last year only
• Restricting the use of HRIG when there is an animal scratch but no bite, unless the scratch is on the head or neck, or the person is immunocompromised, or a higher risk of the animal involved being infected with rabies or ABLV is indicated.

3. Surveillance objectives

• To rapidly identify people potentially exposed to rabies or ABLV and to provide appropriate advice and prophylaxis
• To monitor the epidemiology of rabies/ABLV infection and potential exposures to better inform prevention strategies, including travel advice.

4. Data management

• Only confirmed cases of rabies or ABLV infection should be reported. Data should be entered within one working day of notification.
• Data on potential human exposures and usage of HRIG and rabies vaccine should be collected and reported. De-identified data on potential exposures and vaccine/HRIG use is entered on the national database maintained by the Commonwealth Department of Health and Ageing see: www.outbreak.health.gov.au (log in permission provided by Communicable Diseases and Surveillance branch, DoHA).

5. Communications

Immediately report any suspected or confirmed case of rabies or ABLV infection by telephone to the state/territory Communicable Diseases Branch. Include information on the possible source/s of infection, other people thought to be at risk and any PEP recommendations. If local transmission of rabies is suspected the appropriate state or territory veterinary authority should be contacted urgently or phone the national Emergency Animal Disease Watch Hotline on 1800 675 888 (answered locally in each jurisdiction).

6. Case definition

Only confirmed cases of rabies or ABLV infection are notifiable. The current surveillance case definition can be found at: http://www.health.gov.au/casedefinitions.

7. Laboratory testing

Testing guidelines - humans
Testing for rabies or ABLV is indicated for persons where rabies or ABLV infection is being considered in the differential diagnosis of a clinically compatible illness. No laboratory tests are currently available to diagnose rabies and ABLV infection in humans before the onset of clinical disease. In the early stages of disease, saliva and CSF can be tested by virus culture and PCR. Antibody testing can also be performed on CSF. A positive serum antibody test is diagnostic if a person has never been immunised against rabies and can assist in the diagnosis of rabies or ABLV infection in advanced clinical disease. Any negative test on a symptomatic person is not definitive, as viral shedding in body secretions is intermittent and repeat testing may be indicated. Post mortem, the standard diagnostic techniques include positive fluorescent antibody test (FAT) and PCR on fresh brain smears. Further information is available from the Public Health Laboratory Network (PHLN) case definition website:
www.health.gov.au/internet/main/publishing.nsf/Content/laboratory+case+definitions-1
Refer to The Australian Immunisation Handbook for information on routine serological testing for immunity in people who may be occupationally exposed to rabies or ABLV or who have impaired immunity.

Testing and specimen submission guidelines - animals
Testing of animals for rabies or ABLV is indicated in any situation where a person has been exposed to a potentially infected animal. A positive result from FAT, virus culture or PCR on fresh brain smear of the animal is diagnostic of rabies/ABLV infection. Where possible, PHU staff should arrange for safe handling, euthanasia where relevant and ABLV testing of bats that have been involved in potential human exposures. The process by which bats or bat specimens are to be transported to the appropriate reference laboratory should be documented in protocols within each state and territory. Before shipping specimens, submitters should contact the receiving laboratory to confirm arrangements for sampling, transport and specimen reception.
Occasionally, implicated animals may be tested in overseas countries where Australians have been exposed - PHUs should endeavour to liaise with the overseas laboratory or public health authorities in such circumstances to ascertain the result.

Reference laboratories
The diagnosis of human and animal rabies or ABLV infection can be confirmed by the Australian Animal Health Laboratory (AAHL) or Queensland Health Forensic and Scientific Services (FSS). AAHL and FSS offer both nucleic acid testing and serology. A range of other animal and human health laboratories can perform serology and a small number can perform PCR for ABLV. Reference laboratories can provide advice on interpretation of test results.

Australian Animal Health Laboratory
5 Portarlington Rd
East Geelong
VIC 3219
Ph 03 52275000
Fax 03 52275555

Queensland Health
Forensic and Scientific Services
39 Kessels Road
Coopers Plains
QLD 4108
Ph 07 32749111
Fax 07 32749119

NSW specific
Guidelines for the testing of bats in NSW is available on Popnet. Testing can be performed at EMAI.

State Veterinary Diagnostic Laboratory (SVDL)
Elizabeth Macarthur Agricultural Institute (EMAI)
Woodbridge Road
Menangle NSW 2568.

The laboratory can be contacted by telephoning 1800 675623 during office hours. After hours contact details are available in the Popnet document.

8. Case management

Response times
On the same day of notification of a confirmed case of human disease begin follow up investigation and notify the state/territory Communicable Diseases Branch.

Response procedure
Case investigation
PHU staff conducting the investigation should ensure that action has been taken to:

• confirm the onset date and symptoms of rabies or ABLV illness
• confirm results of laboratory tests
• seek the doctor's permission to contact the case (where possible) or relevant care-giver
• interview case (if possible) or carer and determine source of infection - see Exposure Investigation.

Exposure Investigation
Determine the history of contact with bats (in Australia or overseas) or any other mammal in a rabies-endemic country. Determine the type of animal (and for bats the species if possible), the circumstances and type of exposure, and whether other people or animals may also have been exposed.

Case treatment
There is no known effective treatment for rabies or ABLV infection. A small number of cases of survival from rabies following intensive experimental and/or supportive treatment have been reported.^{22, 23, 24}

Education
The rabies/ABLV fact sheet should be available to carers, and provides information about the nature of infection and mode of transmission. See Appendix 5.

Isolation and restriction
Isolate patient with standard and contact precautions for the duration of the illness.

Active case finding
Active case finding should occur to determine if any other people or animals were exposed to the source animal of the case. Exposed people should be urgently assessed for post-exposure prophylaxis; exposed animals should be managed by veterinary authorities.

9. Control of environment

Any suspected infected animals should be isolated from other animals and humans, and veterinary investigation/management sought. For overseas exposures to dogs or cats where observation of the suspected animal is possible, information on whether the dog or cat remained healthy at least 10 days after the exposure incident may be useful for assessing risk of infection and the need for completion of PEP.

Environmental contamination by infected animals is considered negligible; this is based on knowledge of persistence of the classical rabies virus, which is fragile and does not survive for long outside the host. ²⁵
It is readily inactivated by heat and direct sunlight. Although less is known about the persistence of ABLV in the environment, bats that have been dead for longer than 4 hours are no longer considered infectious for ABLV.¹⁵
Bat blood, urine, and faeces are not considered to be infectious. ¹⁵

10. Contact management

Notification of contacts
Contact tracing is required to provide advice and post-exposure prophylaxis so as to prevent disease in contacts.

Contact definition
Contacts are defined as

1. Persons who have been exposed to the saliva or neural tissue of an infectious person through mucous membrane or broken skin contact, or
2. Persons who have had mucous membrane or broken skin contact with potentially infected animals. This includes any bat in Australia or overseas, and any wild or domestic mammal in a rabies-endemic country.

Prophylaxis
Post-exposure prophylaxis is recommended for persons who fit the contact definition above. See Management of potential human exposure to rabies and ABLV, and follow-up using Rabies/ABLV post-exposure prophylaxis form (see example in Appendix 4).

Education
The rabies/ABLV fact sheet should be available to inform exposed contacts about the nature of infection and mode of transmission. See Appendix 5.

Isolation and restriction
None required.

11. Special situations

Domestic animal exposed to a bat in Australia
There is currently no evidence that wild or domestic mammals in Australia, other than bats, have ever naturally contracted ABLV infection, and no evidence that ABLV has ever been passed from a wild (non-bat) or domestic animal to a human. There is, however, a theoretical possibility that transmission to domestic animals could occur occasionally, and a theoretical (although even more remote) possibility that a domestic animal so infected could transmit infection to a human.

Follow-up by PHUs of incidents involving domestic animals which have suffered bites or scratches from bats is not required routinely. PHUs should, however, provide advice in accordance with this guideline if contacted by concerned owners. The AUSVETPLAN 2009 disease strategy for ABLV recommends testing of the bat involved in an exposure to a domestic animal. Unless the bat is proven to be negative, veterinarians are advised to take one of three options in regards to the animal: vaccinate; observe under formal or informal quarantine; or euthanase.¹⁴

If a domestic animal which has been bitten or scratched by a bat subsequently bites or scratches a human, an expert panel may be convened to advise on management, at the discretion of the managing public health officer. If post-exposure prophylaxis is to be offered to human contacts in any situation involving domestic animals which have suffered bites or scratches from bats, in the absence of a defined human exposure (i.e. bite, scratch or mucous membrane exposure) to the bat, an expert panel should always be convened beforehand.

12. References

1. Heymann DL, editor. Control of communicable diseases manual. 19th ed. Baltimore: United Book Press, 2008.
2. World Health Organization. Rabies factsheet no.99. [updated Sept 2010; cited 23 Sept 2010]. Available from: http://www.who.int/mediacentre/factsheets/fs099/en/
3. Centers for Disease Control and Prevention. Investigation of rabies infections in organ donor and transplant recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR 2004, 53(26):586-9.
4. Centers for Disease Control and Prevention. Human-to-human transmission of rabies via a corneal transplant-France MMWR 1980, 29(3):25-26.
5. Winkler WG, Fashinell TR, Leffingwell L, Howard P, Conomy P. Airborne rabies transmission in a laboratory worker. JAMA; 1973, 226(10):1219-21.
6. Centers for Disease Control and Prevention. Rabies in a laboratory worker - New York. MMWR; 1977, 26:183-84.
7. Winkler WG, Baker EF, Jr., Hopkins CC. An outbreak of non-bite transmitted rabies in a laboratory animal colony. Am J Epidemiol; 1972, 95(3):267-77.
8. Davis AD, Rudd RJ, Bowen RA. Effects of aerosolized rabies virus exposure on bats and mice. J Infect Dis; 2007, 195(8):1144-50.
9. Hanna JN, Carney IK, Smith GA, Tannenberg AE, Deverill JE, Botha JA, et al. Australian bat lyssavirus infection: a second human case, with a long incubation period. Med J Aust; 2000, 172(12):597-9.
10. Jackson AC. Rabies. Neurol Clin; 2008, 26(3):717-26.
11. Hattwick MA. Human Rabies. Public Health Rev; 1974, III(3):229-74.
12. World Health Organization. Rabies vaccines: WHO position paper. Wkly Epidemiol Rec; 2010, 32(85):309-20.
13. Coleman PG, Fèvre EM, Cleaveland S. Estimating the public health impact of rabies. Emerg Infect Dis; 2004, 10(1):140-2.
14. Animal Health Australia (2009). Disease strategy: Australian bat lyssavirus (Version 3.0). Australian Veterinary Emergency Plan (AUSVETPLAN) Edition 3, Canberra, ACT. Available from: http://www.animalhealthaustralia.com.au/wp-content/uploads/2011/04/ABL-07EDIT20Jan10.pdf
15. Australian Technical Advisory Group on Immunisation, Australian Government Department of Health and Ageing. The Australian Immunisation Handbook. 9th ed. Canberra: Australian Government, 2008.
16. Australian Technical Advisory Group on Immunisation Australian Government Department of Health and Ageing (2011). ATAGI Rabies Working Party Report. Canberra.
17. Warrell MJ, Nicholson KG, Warrell DA, Suntharasamai P, Chanthavanich P, Viravan C, et al. Economical multiple-site intradermal immunisation with human diploid-cell-strain vaccine is effective for post-exposure rabies prophylaxis. Lancet; 1985, 1(8437):1059-62.
18. Suntharasamai P, Warrell MJ, Viravan C, Chanthavanich P, Looareesuwan S, Supapochana A, et al. Purified chick embryo cell rabies vaccine: economical multisite intradermal regimen for post-exposure prophylaxis. Epidemiol Infect; 1987, 99(3):755-65.
    Rupprecht CE, Hanlon CA, Hemachudha T. Rabies re-examined. The Lancet Infectious Diseases; 2002, 2(6):327-43.
19. Kaplan MM, Cohen D, Koprowski H, Dean D, Ferrigan L. Studies on the local treatment of wounds for the prevention of rabies. Bull World Health Organ; 1962, 26:765-75.
20. Dean DJ, Baer GM, Thompson WR. Studies on the local treatment of rabies-infected wounds. Bull World Health Organ; 1963, 28(4):477-86.
    Willoughby RE, Jr., Tieves KS, Hoffman GM, Ghanayem NS, Amlie-Lefond CM, Schwabe MJ, et al. Survival after treatment of rabies with induction of coma. N Engl J Med; 2005, 352(24):2508-14.
    Centers for Disease Control and Prevention. Presumptive Abortive Human Rabies - Texas, 2009. MMWR 2010, 59(7):185-90.
    Centers for Disease Control and Prevention. Recovery of a patient from clinical rabies - California, 2011 MMWR 2012, 61(4):61-65.
21. Animal Health Australia (2011). Disease strategy: Rabies (Version 3.0). Australian Veterinary Emergency Plan (AUSVETPLAN), Edition 3, Primary Industries Ministerial Council, Canberra, ACT. Available from: http://www.animalhealthaustralia.com.au/wp-content/uploads/2011/04/RABIES3_0-11-FINAL2May11.pdf

13. Jurisdiction specific issues

Information on State and Territory Public Health Legislation, the Quarantine Act 1908 and the National Health Security Act 2007:
http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-state-legislation-links.htm

14. Appendices

• Appendix 1. Vaccine booster dose algorithm for protection against rabies or ABLV
• Appendix 2. Rabies post-exposure management algorithm
• Appendix 3. Australian bat lyssavirus (ABLV) post-exposure management algorithm
• Appendix 4. Rabies and ABLV post-exposure prophylaxis form
• Appendix 5. Rabies and Australian bat lyssavirus (ABLV) fact sheet
• Appendix 6. PHU rabies and ABLV follow-up checklist