A Proposal for National Rabies Guidelines in the Setting of Mass Bat Exposures

Key Objectives:
To address a perceived need for national public health guidance for rabies in the setting of mass bat exposures (MBE), a MBE working group, comprised of various state and federal public health experts in bat rabies, was convened in 2015 to develop clear national guidelines and algorithms when handling MBE associated with rabies. The key points of discussion will include developing: an accurate working definition of MBE, appropriate scenario-specific tools that will be utilized in MBE investigations, a clear algorithm, and guidelines that will supplement the current non-MBE scenario Advisory Committee on Immunization Practices (ACIP) recommendations.

Brief Summary:
Current guidelines in the setting of exposures to potentially rabid bats established by the ACIP address post-exposure prophylaxis (PEP) administration in situations where a person may not be aware that a bite or direct contact has occurred, and the bat is not available for diagnostic testing. These include instances when a bat is discovered in a room where a person: awakens from sleep, is a child without an adult witness, has a mental disability, or is intoxicated. The current ACIP guidelines, however, do not address PEP in the setting of multiple persons exposed to a bat or a bat colony, otherwise known as MBE. Numerous MBEs have been reported in published literature including over 500 people assessed for co-habitation by a bat colony and a hospital infested with bats where approximately 200 people over a 12 month period were assessed for exposures. Due to a dearth of recommendations for response to these events, the reported reactions by public health agencies have varied widely. To address this perceived limitation, a survey of 45 state public health agencies was conducted to characterize prior experiences with MBE and practices to mitigate the public health risks. In general, most states (71% of the respondents), felt current ACIP guidelines were unclear in MBE scenarios. Thirty-three of the 45 states reported prior experience with MBE, receiving an average of 16.9 MBE calls per year and an investment of 106.7 person-hours annually on MBE investigations.  PEP criteria, investigation methods, and the experts recruited in MBE investigations varied between states. These dissimilarities could reflect differences in experience, scenario and resources. The lack of consistency in state responses to potential mass exposures to a highly fatal disease along with the large contingent of states dissatisfied with current ACIP guidance, warrants the development of national guidelines in MBE settings.