TY - JOUR
AU - USA, Ronald L. Burke, VC
AB - ABSTRACT As medics and doctors prepare for deployment to a combat zone, there are countless specified and implied tasks needed to prepare the medical support of an Infantry unit in theater. Appropriately, units spend the lion share of their efforts in trauma training and medical readiness (vaccinations, medication prescriptions, eye glasses, etc.) while ensuring that the sets, kits, and outfits are all fully stocked with the required items needed to execute the mission. Unfortunately, this training and preparation included little on the major challenges units currently face from rabies. With the unfortunate recent death of a soldier from rabies, medical personnel were required to become experts in animal control, the prevention of animal bites and scratches, and the most appropriate treatment of service members with potential exposure to rabid animals. This article will discuss the challenges of rabies management in Afghanistan, appropriate provider and unit preparation to minimize risk of developing rabies, the need for establishment of an animal control team and prerequisite training of soldiers, leaders, and medics before and during deployment. Finally, we will review published guidelines for treating individuals exposed to rabies with a discussion of our units experience with postexposure prophylaxis. INTRODUCTION Beginning in the Fall of 2010, Task Force 1 to 2 began to prepare in earnest for its mission to Afghanistan, which included individual soldier medical readiness and training of medical staff. Individual soldier readiness was tracked by the command, which ensured all required examinations, screenings, vaccinations, prescriptions, eye glasses, etc. were current according to appropriate regulations. We also frequently communicated with the unit we would replace to determine what medical equipment and supplies were available and what medical conditions we would encounter to ensure that our sets, kits, and outfits were fully stocked with the items we needed to execute our mission and identify training requirements to ensure the medical staff was prepared. The medical classes, courses, and training focused on care under fire, tactical field care and Role 1 Aid Station care and were primarily directed at the four most common causes of preventable death on the battlefield: hemorrhage, tension pneumothorax, airway obstruction, and hypothermia.1 All medics attended the Tactical Combat Casualty Care that trains soldiers in care under fire, tactical field care, and tactical evacuation. In addition, medics attend a Combat Casualty Care Course that focuses on treating, stabilizing, and evacuating patients with combat wounds. Finally, just before deployment our medics attended Brigade Combat Team Trauma Training that further hones their skills in the acute management of trauma patients on the battlefield. Medical providers (physicians and physician assistants) typically have a 1 week trauma refresher course, the Tactical Combat Medical Course. Although most medics and providers would agree that they were adequately trained to treat trauma injuries on a kinetic battlefield, they would also all agree they received very little training in environmental, waterborne, foodborne, and animal contact diseases. Although Preventative Medicine teams exist at Brigade and Division, these assets usually rotate throughout a large “battle-space” and are frequently unavailable for direct consultation except via telephone or email. This leaves the responsibility of monitoring and practicing preventative medicine tasks to the unit medics and providers and company and battalion level field sanitation teams who receive a 1 week course in field sanitation. Shortly after arriving in country, we experienced a significant shift in focus after the unfortunate death of a 10th Mountain Division soldier who died shortly after returning from Afghanistan in our area of operation.2 The individual, a 24-year-old male who, despite aggressive treatment, died from complications of a rabies infection after being bitten by a dog during his tour in Afghanistan. Rabies is endemic on all continents except Australia with more than 55,000 deaths reported annually. Immediate wound cleansing and immunization can prevent this very lethal disease (90% fatality rate). The global vaccination of over 15 million people is estimated to prevent 327,000 rabies deaths each year.3 The risk of rabies in the United States, and other developed nations, is mainly from wild animals especially bats and raccoons because of the rigorous application of rabies vaccines within domesticated animals such as dogs and cats.4 The U.S. Centers for Disease Control and Prevention (CDC) estimates the annual costs of rabies vaccinations for animals in the United States to be $300 million.5 In developing countries, like Afghanistan (per capita gross domestic product is $900) rabies is ubiquitous because of the prohibitive cost of extensive prophylactic vaccination.6 In 2002, an average of four new cases per day was reported in Kabul alone, and neighboring Pakistan reported 2 to 5 thousand deaths annually from rabies.7 Unfortunately, U.S. service members often view cats and dogs as “pets” as opposed to rabies carrying vectors (Fig. 1). Although General Order 1B specifically prohibits having pets or making contact with local wild life, it is not always obeyed.8 This may be due to the perceived low threat of rabies by U.S. service members as suggested by accounts of individuals of various ranks petting feral dogs and cats and units with unauthorized mascots. Needless to say, we had issues with potential rabies exposure that we were incompletely prepared to handle. FIGURE 1. View largeDownload slide Friend or Foe. FIGURE 1. View largeDownload slide Friend or Foe. CASES ENCOUNTERED WHILE DEPLOYED During the first 4 months of our deployment, we encountered six soldiers with potential exposure to rabies. The first soldier was exposed when he tried to transport two kittens for euthanasia. Despite wearing leather gloves, the soldier was bitten with a break in his skin. Four additional cases involved an unauthorized unit cat; two soldiers were bitten, two were scratched, and all sought medical attention months after their exposures following a briefing on rabies by their unit medic soldier. All individuals received postexposure prophylaxis in accordance with theater policy. The last exposure involved a member of our animal control team who was assisting with a cat's euthanasia. Again, despite wearing gloves, he was bitten and had a break in his skin. As the soldier had received preexposure prophylaxis he received Day 0 and Day 3 postexposure vaccines. Rabies immunoglobulin (RIG) was not administered initially because of potential interference with the immune response of a previously vaccinated individual, but a serum sample was sent back to Landstuhl Regional Medical Center in Germany to confirm existing immunity (by serology) because confirmatory serum titers for rabies vaccination were not performed before deployment. The testing confirmed preexisting immunity to rabies, so administration of RIG was not necessary. DISCUSSION The death of a U.S. soldier in Afghanistan resulted in increased sensitivity to rabies exposure and animal bite treatment in deployed U.S. personnel. These concerns resulted in wide shortages of both vaccine and RIG throughout eastern Afghanistan. Given the sporadic nature of rabies bites it is not logistically or economically feasible to stock sufficient amounts of RIG at every Level I aid station. Instead, RIG is maintained at Level II aid stations while vaccines are maintained at Level I aid stations (battalion level). The second order effect of this decision was soldiers suspected of rabies exposure required medical evacuation to Level II aid station or the rapid transportation of RIG to the soldier at the Level I aid station. Because the treatment of animal bites in rabies endemic areas is generally viewed as urgency, as opposed to an emergency, either of these two solutions is acceptable for treating patients in a reasonable amount of time. However, given the scarcity of RIG, close coordination throughout the medical logistics system was required to ensure it was available theater-wide in a timely manner. Even with this coordination, precious air assets were sometimes needed to get RIG to a soldier in need. There were several sets of guidelines to consider when dealing with soldiers who have been exposed to rabies. Table I provides a summary of the published recommendations from the various agencies and each is discussed later. Slight differences in these guidelines presented a therapeutic challenge to the provider at a Level I aid station who must decide which patients require evacuation for postexposure prophylaxis as well request additional vaccine for treatment of nonbite exposure. TABLE I. Rabies Prophylaxis Recommendations from the World Health Organization3, U.S. Centers for Disease Control and Prevention5, and Local U.S. Military Theater Policy9 Organization  Bite Exposure  Nonbite Exposure (i.e., Scratches)  Comments  World Health Organization  Wash  Wash  No RIG for lower risk exposures  RIG  Vaccine  Vaccine    U.S. Centers for Disease Control and Prevention  Wash  Wash  Requires medical provider to assess level of exposure risk and corresponding treatment  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    Afghanistan Theater Policy—U.S. Military  Wash  Wash  Minimum treatments required as well as administrative reporting requirements  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    Organization  Bite Exposure  Nonbite Exposure (i.e., Scratches)  Comments  World Health Organization  Wash  Wash  No RIG for lower risk exposures  RIG  Vaccine  Vaccine    U.S. Centers for Disease Control and Prevention  Wash  Wash  Requires medical provider to assess level of exposure risk and corresponding treatment  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    Afghanistan Theater Policy—U.S. Military  Wash  Wash  Minimum treatments required as well as administrative reporting requirements  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    RIG, rabies immunoglobulin. View Large TABLE I. Rabies Prophylaxis Recommendations from the World Health Organization3, U.S. Centers for Disease Control and Prevention5, and Local U.S. Military Theater Policy9 Organization  Bite Exposure  Nonbite Exposure (i.e., Scratches)  Comments  World Health Organization  Wash  Wash  No RIG for lower risk exposures  RIG  Vaccine  Vaccine    U.S. Centers for Disease Control and Prevention  Wash  Wash  Requires medical provider to assess level of exposure risk and corresponding treatment  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    Afghanistan Theater Policy—U.S. Military  Wash  Wash  Minimum treatments required as well as administrative reporting requirements  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    Organization  Bite Exposure  Nonbite Exposure (i.e., Scratches)  Comments  World Health Organization  Wash  Wash  No RIG for lower risk exposures  RIG  Vaccine  Vaccine    U.S. Centers for Disease Control and Prevention  Wash  Wash  Requires medical provider to assess level of exposure risk and corresponding treatment  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    Afghanistan Theater Policy—U.S. Military  Wash  Wash  Minimum treatments required as well as administrative reporting requirements  RIG  Vaccinate only if suspected contamination with saliva or blood  Vaccine    RIG, rabies immunoglobulin. View Large The World Health Organization (WHO) recommendations are the most conservative and proscriptive. They divide categories of exposure into three categories (Table II).3 Category I is minimal exposure and includes touching or feeding and animal and licks on intact skin. This is an insignificant exposure and does not require postexposure prophylaxis. Category II includes nibbling of uncovered skin, minor scratches or abrasion without bleeding. Although this constitutes a minimal risk, the WHO recommends immediate vaccination after local treatment of wound. Finally, Category III is single or multiple transdermal bites or scratches with broken skin and contamination with saliva or specifically exposure to bats. For this more serious exposure, the WHO again recommends immediate wound cleaning, vaccination, and RIG administration. TABLE II. World Health Organization Recommended Postexposure Prophylaxis for Rabies Infection3 Category of Exposure to Suspect Rabid Animal  Postexposure Measures  Category I—touching or feeding animals, licks on intact skin (i.e., no exposure)  None  Category II—nibbling of uncovered skin, minor scratches or abrasions without bleeding  Immediate vaccination and local treatment of the wound  Category III—single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, and a specific mention of exposures to bats  Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound  Category of Exposure to Suspect Rabid Animal  Postexposure Measures  Category I—touching or feeding animals, licks on intact skin (i.e., no exposure)  None  Category II—nibbling of uncovered skin, minor scratches or abrasions without bleeding  Immediate vaccination and local treatment of the wound  Category III—single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, and a specific mention of exposures to bats  Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound  View Large TABLE II. World Health Organization Recommended Postexposure Prophylaxis for Rabies Infection3 Category of Exposure to Suspect Rabid Animal  Postexposure Measures  Category I—touching or feeding animals, licks on intact skin (i.e., no exposure)  None  Category II—nibbling of uncovered skin, minor scratches or abrasions without bleeding  Immediate vaccination and local treatment of the wound  Category III—single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, and a specific mention of exposures to bats  Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound  Category of Exposure to Suspect Rabid Animal  Postexposure Measures  Category I—touching or feeding animals, licks on intact skin (i.e., no exposure)  None  Category II—nibbling of uncovered skin, minor scratches or abrasions without bleeding  Immediate vaccination and local treatment of the wound  Category III—single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, and a specific mention of exposures to bats  Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound  View Large The CDC publishes recommendations for the treatment and prevention of rabies exposures based on the type of exposure occurred.5 The underlying assumption is “rabies is primarily transmitted when the virus is introduced into a bite wound, open cuts in skin, or onto mucous membranes such as the mouth or eyes.” Accordingly, bites are the highest risk exposures and defined as “any penetration of the skin by teeth constitutes a bite exposure.” All bites from a rabid animal or an animal at risk require wound cleansing and immediate RIG and vaccine administration (Table III). Nonbite exposures also pose a potential risk because of the possible “contamination of open wounds, abrasions, mucous membranes, or theoretically, scratches (potentially contaminated with infectious material from a rabid animal).” While admittedly nonbite exposures rarely cause rabies, there have been occasional reports of nonbite exposure rabies transmission, which suggests that such exposures should be evaluated for possible postexposure prophylaxis administration. In Afghanistan, rabies treatment policies for U.S. Forces originate at the theater level under the guidance of the preventive medicine physician (Table IV). These guidelines prescribe the reporting, evaluation, and treatment for potential exposures and mirror almost the CDC recommendations that require RIG and vaccine for a bite exposure in unvaccinated individuals. Nonbite exposures do not require vaccination or RIG unless the scratch is believed to be contaminated with the saliva, blood, or body fluid of an infected or animal with unknown rabies status. All agencies, and Theater policy, agree that simple contact with a rabid animal, such as petting a rabid animal or having contact with the blood, urine, or feces of a rabid animal, does not constitute an exposure and is not an indication for postexposure vaccination. The issue providers face is how does one know whether a scratch is contaminated with saliva? TABLE III. U.S. Centers for Disease Control and Prevention Rabies Postexposure ProphylaxisRecommendations for Nonimmunized and Previously Immunized Individuals5    Nonimmunized Individuals  Previously Immunized Individuals  Wound Cleansing  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  RIG  If possible, the full dose should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from vaccine administration. Also, RIG should not bead ministered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, not more than the recommended dose should be given.  RIG should not be administered.  Vaccine  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14.  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0 and 3.     Nonimmunized Individuals  Previously Immunized Individuals  Wound Cleansing  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  RIG  If possible, the full dose should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from vaccine administration. Also, RIG should not bead ministered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, not more than the recommended dose should be given.  RIG should not be administered.  Vaccine  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14.  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0 and 3.  RIG, rabies immunoglobulin; IM, intramuscular; HDCV, human diploid cell vaccine; PCECV, purified chick embryo cell vaccine. View Large TABLE III. U.S. Centers for Disease Control and Prevention Rabies Postexposure ProphylaxisRecommendations for Nonimmunized and Previously Immunized Individuals5    Nonimmunized Individuals  Previously Immunized Individuals  Wound Cleansing  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  RIG  If possible, the full dose should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from vaccine administration. Also, RIG should not bead ministered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, not more than the recommended dose should be given.  RIG should not be administered.  Vaccine  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14.  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0 and 3.     Nonimmunized Individuals  Previously Immunized Individuals  Wound Cleansing  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine iodine solution should be used to irrigate the wounds.  RIG  If possible, the full dose should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from vaccine administration. Also, RIG should not bead ministered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, not more than the recommended dose should be given.  RIG should not be administered.  Vaccine  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0, 3, 7, and 14.  HDCV or PCECV 1.0 mL, IM (deltoid area), 1 each on days 0 and 3.  RIG, rabies immunoglobulin; IM, intramuscular; HDCV, human diploid cell vaccine; PCECV, purified chick embryo cell vaccine. View Large TABLE IV. U.S. Military Afghanistan Theater Policy9    Definition  Recommended Treatment  Comments  Bite Exposure  Animal bite not further defined.  Immediate PEP should be initiated including vaccine and RIG.  Whenever possible, the animal involved in the bite should be safely retrieved and either quarantined or euthanized for rabies testing. Bites involving military working dogs with current rabies vaccinations requires quarantine the dog for 10 days.  Nonbite Exposure  A is defined as the introduction of saliva or other potentially infectious material (e.g., neural tissue, cerebrospinal fluid, etc.), into fresh, open cuts in skin or mucous membranes. Nonbite exposures very rarely result in rabies transmission.  PEP is not indicated unless the nonbite exposure met the definition of saliva or other potentially infectious material being introduced into fresh, open cuts in skin or onto mucous membranes.  Nonbite exposures other than organ or tissue transplants have almost never been proven to cause rabies.  Nonexposure  Merely touching a rabid animal or coming into contact with blood, urine or feces, and contact of saliva with intact skin does not constitute a legitimate exposure.  PEP is not indicated.  Opportunity to reeducate Soldier to avoid contact with any feral animals as well as actions required if exposed.     Definition  Recommended Treatment  Comments  Bite Exposure  Animal bite not further defined.  Immediate PEP should be initiated including vaccine and RIG.  Whenever possible, the animal involved in the bite should be safely retrieved and either quarantined or euthanized for rabies testing. Bites involving military working dogs with current rabies vaccinations requires quarantine the dog for 10 days.  Nonbite Exposure  A is defined as the introduction of saliva or other potentially infectious material (e.g., neural tissue, cerebrospinal fluid, etc.), into fresh, open cuts in skin or mucous membranes. Nonbite exposures very rarely result in rabies transmission.  PEP is not indicated unless the nonbite exposure met the definition of saliva or other potentially infectious material being introduced into fresh, open cuts in skin or onto mucous membranes.  Nonbite exposures other than organ or tissue transplants have almost never been proven to cause rabies.  Nonexposure  Merely touching a rabid animal or coming into contact with blood, urine or feces, and contact of saliva with intact skin does not constitute a legitimate exposure.  PEP is not indicated.  Opportunity to reeducate Soldier to avoid contact with any feral animals as well as actions required if exposed.  PEP, postexposure prophylaxis. View Large TABLE IV. U.S. Military Afghanistan Theater Policy9    Definition  Recommended Treatment  Comments  Bite Exposure  Animal bite not further defined.  Immediate PEP should be initiated including vaccine and RIG.  Whenever possible, the animal involved in the bite should be safely retrieved and either quarantined or euthanized for rabies testing. Bites involving military working dogs with current rabies vaccinations requires quarantine the dog for 10 days.  Nonbite Exposure  A is defined as the introduction of saliva or other potentially infectious material (e.g., neural tissue, cerebrospinal fluid, etc.), into fresh, open cuts in skin or mucous membranes. Nonbite exposures very rarely result in rabies transmission.  PEP is not indicated unless the nonbite exposure met the definition of saliva or other potentially infectious material being introduced into fresh, open cuts in skin or onto mucous membranes.  Nonbite exposures other than organ or tissue transplants have almost never been proven to cause rabies.  Nonexposure  Merely touching a rabid animal or coming into contact with blood, urine or feces, and contact of saliva with intact skin does not constitute a legitimate exposure.  PEP is not indicated.  Opportunity to reeducate Soldier to avoid contact with any feral animals as well as actions required if exposed.     Definition  Recommended Treatment  Comments  Bite Exposure  Animal bite not further defined.  Immediate PEP should be initiated including vaccine and RIG.  Whenever possible, the animal involved in the bite should be safely retrieved and either quarantined or euthanized for rabies testing. Bites involving military working dogs with current rabies vaccinations requires quarantine the dog for 10 days.  Nonbite Exposure  A is defined as the introduction of saliva or other potentially infectious material (e.g., neural tissue, cerebrospinal fluid, etc.), into fresh, open cuts in skin or mucous membranes. Nonbite exposures very rarely result in rabies transmission.  PEP is not indicated unless the nonbite exposure met the definition of saliva or other potentially infectious material being introduced into fresh, open cuts in skin or onto mucous membranes.  Nonbite exposures other than organ or tissue transplants have almost never been proven to cause rabies.  Nonexposure  Merely touching a rabid animal or coming into contact with blood, urine or feces, and contact of saliva with intact skin does not constitute a legitimate exposure.  PEP is not indicated.  Opportunity to reeducate Soldier to avoid contact with any feral animals as well as actions required if exposed.  PEP, postexposure prophylaxis. View Large Evaluation of these nonbite exposures for postexposure vaccination should be made on a case by case basis, in conjunction with the area veterinarian. The first step is determining the risk of rabies in the region in general. In Afghanistan, the risk of rabies is high. The next step is to evaluate the type of animal involved and the nature of the incident. Small rodents are generally considered extremely low risk. In Afghanistan, dogs and cats are a higher risk. The next step is to determine animal's behavior and the nature of the attack. Unprovoked bites where the victim made no attempt to engage the animal are considered higher risk than bites that occur when the animal is reacting in self-defense. An animal acting strangely at the time of the attack or afterward is of particular concern for rabies infection. In addition, if the animal has a history of a licensed rabies vaccination (e.g., a military working dog), postexposure prophylaxis is not warranted. Finally, the disposition of the animal must be considered. If a stray animal is captured, it can be euthanatized and the neural tissue sent for rabies tests; the only definitive test for rabies requires a biopsy of neural tissues. Neural tissue from animals euthanized in Afghanistan must be sent to Landstuhl Regional Medical Center for pathological examination with direct fluorescent antibody testing. Typically, after receiving a bite from a local animal, a soldier would receive RIG and begin the vaccination series; if the neural pathology result returned negative for rabies, the series could be halted at three doses, the doses needed for preexposure prophylaxis. The other issue that was discussed was the number or vaccinations required as part of postexposure prophylaxis to prevent rabies. The Advisory Committee on Immunization Practices has changed its recommendations from a five injection series after exposure to a four injections series commencing as soon as possible after exposure (Day 0) and then finishing with follow-up immunization on Days 3, 7, and 14.5 Each injection should contain 1-mL dose of human diploid cell vaccine or purified chick embryo cell vaccine. However, as deployed service members are often taking malaria prophylaxis they should receive a fifth injection on Day 28 as antimalarials may reduce the immune response to the rabies vaccine. Preventing Future Cases and Reducing Exposures In September 2011, the U.S. Army Medical Command published an Operations Order on rabies risk during military deployments.9 The order established procedures for identification, notification, evaluation, and treatment of all personnel (U.S. and partner military, Department of Defense civilians, and eligible contractors) who were potentially exposed to rabies during their current or recent deployment. Although early identification and case management in theater is the primary goal, the order further directed the retrospective review of DD Form 2796—Post-Deployment Health Assessment (PDHA) or DD Form 2900—Health Reassessment forms to identify exposed individuals who have already redeployed. The order also provides a link for online training (https://www.projectimmunereadiness.amedd.army.mil/), which is designed to educate physicians, nurses, and other health care workers with regard to rabies, the vaccine, dosage and administration details, indications and contraindications/precautions, patient education, and resources related to immunization, including the vaccine information statement. Additional outcomes of the order currently under development include an automated animal bite tracking system, Armed Forces Health Longitudinal Technology Application (AHLTA) animal bite management templates, and a U.S. Army Public Health Command Technical Guide for management of animal exposures. Although postexposure prophylaxis is effective when administered properly and in a timely manner, the most effective rabies prevention method is prevention of exposure. A key component of this is avoidance through understanding of the potential risk associated with animal contact. To this end, U.S. Army Public Health Command has developed several posters intended to raise service member awareness on the risk of rabies, especially with regard to dogs and cats.10 Unit leaders and medical personnel must remain diligent in their risk communication efforts and enforcement of the ban on pets. The risk of rabies exposure can be further reduced through coordination with local military veterinary services and Department of Defense approved contractors for humane animal control. Finally, any nonvaccinated animal that bites or otherwise potentially exposes a service member to rabies shall be humanely euthanized and a specimen should be submitted for laboratory testing. The experiences of the prior medical unit at our forward operating base highlight the importance of this testing for confirmation of rabies exposure as 15% of all specimens were positive. It is important to note that five of the six exposures our unit saw may have been prevented by following the above guidance. Ensuring only trained individuals transport animals may have prevented the first case and enforcement of the ban on pets would have prevented four additional cases. Recommendations In preparation for deployment to Afghanistan, or other country with high indigenous rabies rates, there are several easy things to do to minimize risk to your soldiers and conserve the fighting strength of the unit in addition to standard medical readiness procedures and trauma training. The first thing is to identify a team of soldiers including a responsible Non-Commissioned Officer to comprise the Animal Control/Rabies Prevention Team. These teams should be established at company and battalion level and will need to complete recommended preexposure immunizations. Vaccinated individuals should have their titer checked every 2 years or have a booster vaccination every 5 years. The team should also go through training given by area veterinary and vector control/pest management resources covering rabies prevention and techniques in humane animal control measures (capture and euthanasia). Units should procure small and large cages before deployment to capture cats and dogs as may be difficult to obtain while deployed. Upon deployment, a member of the animal control team, or at least a person with an understanding of the rabies threat should be one of the first to arrive in the area of operations. Early arrival allows a quick assessment of the current risk and facilitates the transfer of the previous unit's experiences in the area with respect to feral animals as well as any “lessons learned”. The main body of the unit should undergo a refresher training reviewing the risks of rabies as well as actions to be taken if exposed to an animal in theater. The medical team must be prepared for the expeditious evaluation and treatment of any soldiers who are potentially exposed to rabies. Adequate supplies of vaccine should be kept on hand to treat patients with immediate wound cleansing and vaccination as appropriate. Administration of RIG as needed at Level I facilities would require maintaining a supply of RIG at each Level I facility. Although this policy would eliminate the need for evacuation to a Level II, the number of facilities in theater would likely make this policy unacceptably expensive and difficult given the current shortages of RIG and vaccine in theater. Another key lesson learned was the importance of proper documentation using the Army's electronic medical records systems, AHLTA and Medical Protection System. Following the soldier's death from rabies, electronic medical records allowed military and public health officials to verify that exposed soldiers were receiving appropriate and timely medical care after potential exposure. Multiple entries into the electronic medical record system needed in these cases required that clinical entries be made into both AHLTA-Tactical and Medical Protection System. Furthermore, the complete documentation of multiple encounters for the same patient, while taxing on medical personnel focused on treating combat injuries, is essential for documenting the quality of care the soldiers received. On redeployment, soldiers must again be questioned about possible exposure to rabies during the PDHA. These questions in the PDHA can identify soldiers who perhaps failed to seek medical attention immediately after exposure. Identification of these individuals facilitates their appropriate treatment before moving back to their duty station and will save lives. ACKNOWLEDGMENTS This article is dedicated to the memory of U.S. Army Specialist Kevin A. Shumacker, who died of rabies contracted while he was supporting Operation Enduring Freedom in Afghanistan. REFERENCES 1. Holcomb JB, McMullin NR, Pearse L, et al.   Causes of death in U.S. Special Operations Forces in the global war on terrorism: 2001–2004. Ann Surg  2007; 6: 1158– 1164. 2. Fort Drum Public Affairs A 10th Mountain Division Soldier has died after contracting rabies. Press Release No. 1109-02 . Available at http://www.drum.army.mil/news/Article.aspx?Date=10/13/2011&ID=3484; accessed October 13, 2011. 3. World Health Organization Rabies, Fact Sheet No. 99 . Available at http://www.who.int/mediacentre/factsheets/fs099/en/; accessed October 13, 2011. 4. Blanton JD, Palmer D, Dyer J, Rupprecht CE Rabies surveillance in the United States during 2010. J Am Vet Med Assoc  2011; 6: 773– 83. Google Scholar CrossRef Search ADS   5. Centers for Disease Control and Prevention Rabies . Available at http://www.cdc.gov/rabies/; accessed October 13, 2011. 6. Central Intelligence Agency The World Factbook : Afghanistan. Available at https://www.cia.gov/library/publications/the-world-factbook/geos/af.html; accessed October 13, 2011. 7. Beltramello C, Haskew C, Connolly M WHO communicable disease profile on Afghanistan and neighboring countries . Available at http://www.who.int/diseasecontrol_emergencies/toolkits/Afghanistan_profile.pdf; accessed December 21, 2011. 8. U.S. Central Command General Order Number 1-B: Prohibited Activities for U.S. Department of Defense Personnel Present with the United States Central Command (USCENTCOM) Area of Responsibility (AOR) . MacDill AFB, FL, 2006. Available at http://www.cusnc.navy.mil/ctf-ia/documents/General%20Order%201B1.pdf; accessed October 31, 2011. 9. U.S. Army Medical Command Operation Order 11-56: Public Health Response to Rabies Risk During Overseas Contingency Operations . Falls Church, VA, 2011. Available at http://phc.amedd.army.mil/topics/discond/aid/pages/rabies.aspx. 10. U.S. Army Public Health Command Rabies . Available at http://phc.amedd.army.mil/topics/discond/aid/Pages/Rabies.aspx; accessed October 31, 2011. Reprint & Copyright © Association of Military Surgeons of the U.S.
TI - Rabies, Readiness, and Role 1 Medical Care
JF - Military Medicine
DO - 10.7205/MILMED-D-13-00088
DA - 2013-10-01
UR - https://www.deepdyve.com/lp/oxford-university-press/rabies-readiness-and-role-1-medical-care-58E06aArN6
SP - e1159
EP - e1164
VL - 178
IS - 10
DP - DeepDyve
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