In 2018, 74 healthcare workers in Utah were exposed to a patient with undiagnosed rabies, prompting rapid administration of post-exposure prophylaxis (PEP) for a disease that nearly always is fatal once symptoms begin.
Although no occupational transmission of rabies to healthcare workers has been documented, these exposures are traumatic to staff, require labor-intensive follow-up, and are costly and disruptive to the affected hospital and health department.
The CDC has updated its guidelines for occupational exposure to rabies to emphasize the rare but real risk to healthcare workers.1
“An exposure to rabies virus in a healthcare setting could include being bitten by a potentially infectious patient,” the CDC noted. “Rabies virus is transmitted through direct contact (e.g., through broken skin or mucous membranes in the eyes, nose, or mouth) with saliva, tears, and lacrimal secretions, or brain/nervous system tissue from an infected animal or person. Bite and non-bite (e.g., cerebrospinal fluid, brain tissue) occupational exposures from an infected person could theoretically transmit rabies to healthcare personnel, but no such cases have been confirmed.”
Importantly, urine, blood, and feces from a rabies patient are not infectious. Likewise, casual contact with a person with rabies is not considered a risk for infection, and the rabies virus is not transmitted through clothes or bedding.
“Person-to-person transmission of rabies is rare and has been reported almost exclusively via cornea, tissue, and organ transplantation,” the CDC said.
Do Not Handle Bats
In the Utah case, PEP also was administered to 30 community and family members, some of whom reported a 55-year-old man handled bats in his residence. Bats are the primary source for rabies infections in the United States. The man’s family members did not know the risk of bats but described an invasion of them in their residence.
“The patient’s family reported that a large number of bats had occupied their attic and frequently were found in the living area of the home, particularly in the master bedroom,” CDC outbreak investigators reported.2 “On multiple occasions, the patient had removed bats from the home with his bare hands, and on one occasion, the patient awoke to find a bat near his head.”
It is estimated less than 1% of bats carry rabies, with transmission to humans usually occurring because they handle the mammals. The simplest advice is to not handle bats, particularly those acting strangely like staying on the ground or flying during the daytime.
The patient died 19 days after symptom onset, but many healthcare workers were potentially exposed before the diagnosis was confirmed because he was transferred to several different healthcare settings.
“Rabies onset is characterized by a non-specific prodrome that could be mistaken for other diseases,” the CDC noted. “The first symptoms of rabies may be very similar to those of an influenza-like illness, including general weakness or discomfort, fever, or headache. These symptoms may last for days.”
CDC Recommendations
The CDC rabies guidelines include these three recommendations:
- Administer PEP in accordance with CDC recommendations and in consultation with federal, state, and local public health authorities;
- Work restrictions are unnecessary for asymptomatic healthcare workers exposed to the virus;
- Healthcare workers with a suspected or confirmed infection should be restricted from work in consultation with federal, state, and local public health authorities.
The CDC gave these recommendations to prevent transmission of rabies:
- Healthcare workers should use standard precautions — which may include a gown, gloves, eye protection, and face mask — for patients with suspected or confirmed infection.
- Rule out more common causes of encephalitis before considering rabies.
- Administer PEP to those exposed to rabies and wash any related wounds promptly.
“As the disease progresses, a rabies patient may experience delirium, abnormal behavior, hallucinations, hydrophobia, dysphagia, and insomnia,” the CDC stated. “Occasionally, rabies may present as a paralytic syndrome.”
PEP Is Essential
Rabies almost always is fatal if symptoms begin and PEP has not been administered.
“Among those without a history of receiving pre- or post-exposure prophylaxis, [fewer] than 10 documented cases of human survival from rabies have been reported,” the CDC reported. “The majority have had significant lifelong neurological deficits.”
Making case identification more difficult is the broad range of the incubation period for human rabies, which is typically one to three months, but also can begin in days or not surface for years.
REFERENCES
- Centers for Disease Control and Prevention. Rabies. Last reviewed Nov. 1, 2022.
- Peterson D, Barbeau B, McCaffrey K, et al. Human rabies — Utah, 2018. MMWR Morb Mortal Wkly Rep 2020;69:121-124.
The CDC has updated its guidelines for occupational exposure to rabies to emphasize the rare but real risk to healthcare workers.
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