[log in to unmask] wrote:
> Insectiverous bats, I understand, carry European bat lyssavirus which is a
> strain of rabies that responds to rabies vaccine. There was a bat handler in
> Tayside who died of rabies a few years ago
> (http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve
> <http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=1
> 2938204&dopt=AbstractPlus> &db=PubMed&list_uids=12938204&dopt=AbstractPlus)
> - a case I remembered when a bat handler phoned for advice having been
> bitten during my first A&E job. The only other thing I remember about it is
> that it was unbelievably difficult trying to get hold of the vaccine!
>  
> Rhona


Wow - I last posted on this subject to the list in 2001! .... (see http://www.jiscmail.ac.uk/cgi-bin/webadmin?A2=ind0107&L=ACAD-AE-MED&P=R8489&I=-3 ), and things have changed a bit..... not least of all that I no longer have a Consultant Virologist just up the corridor to ask!, as well as fatal cases (acquired from bats in the UK).


A licensed bat handler should have pre-exposure immunisation. Rabipur is one such preparation, and should be available through the usual supply chain, although I've never tried!.

If your bat handler presented today post-bite (and he hadn't had pre-exposure immunisation or it was a non-immunised person bitten by a bat) I would likely advise post exposure vaccine and immunoglobulin (HRIG) ; there have been cases of fatal EB lyssavirus infection, and bats normally avoid human contact - so there must be concern the bat was unwell / infected.

Rhona, I notice you are in Scotland, and I don't know what the supply situation for post-exposure HRIG/ vaccine is up there. In England the supplies are held centrally at the Virus Reference Division, HPA Centre for Infections, with some stocks at some microbiology labs (usually ones that used to be PHLS labs, but not all of the ex-PHLS labs). The lab I work in is one such lab, and we occaisionally get 'bat bite' queries.

We keep a stock of both Rabipur and HRIG for post-exposure use ; there is no charge for these to the patient for post-exposure use (an anomaly, as they'd have to pay for vaccine for pre-exposure occuptaional purposes!).

I'd suggest contacting your local medical microbiologist if you needed clarification of supply sources for an urgent enquiry (bite to face, small child, or bite some time previously). The urgency here is that the virus travels via the CNS to the brain - bites closer to the brain or where treament is delayed carry a higher risk.

http://www.hpa.org.uk/cdr/archives/2005/cdr3005.pdf details some fatal (UK) cases of imported rabies,
http://www.hpa.org.uk/cdr/archives/2002/cdr4802.pdf confirms rabies as the cause of the fatal illness of a Scottish bat handler, which had been reported at:
http://www.hpa.org.uk/cdr/archives/2002/cdr4702.pdf - which gives more detailed advice regarding bat contact.

http://www.hpa.org.uk/infections/topics_az/rabies/menu.htm is a good source of info, and the guidelines sub-page (and immunoglobulin handbook) are handy - there is a catch for the unwary here, as the immunoglobulin comes in 2.2 ml vials, but the concentration per ml can vary!. The current UK batch (SRCN 7503) contains a high level of antibody (500iu in 1.1mls) - different to previous batches. Again, for non-urgent queries your national virus reference lab can advise, and for an urgent query I'd advise speaking to your local medical microbiologist (though I am not unbiased as I'm looking to keep myself in work! ;) )

The "Green Book" (available at http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254 ) has useful info, and Rabies is covered in Chapter 28. (This includes a suggestion for getting hold of rabies vaccine in Scotland, [p. 341] - I take it this was not your experience, Rhona?)

Whilst not wanting to teach my Emergency Medicine colleagues to suck eggs ... I also tag on that they person calling me about bat-bites / rabies should not allow the 'wow' factor of a rabies query to make them miss sight of the less glamorous bacterial infections - and I'll offer advice on antibiotics and checking tetanus status if they have been overlooked.

A practical point regarding HRIG : unlike the vaccine it is intolerant of being out of a 'cold chain'. Supplies sent out from VRD, CfI arrive in an impressively sized cold box, and the labs that hold stocks locally can't just "stick it in a Jiffy bag and post it out", unlike some vaccines that will tolerate this.

In practice this usually means asking our ED to administer the first dose of vaccine and the HRIG, and getting the patient to come to our ED and then take away the subsequent doses of vaccine (which are more tolerant of temperature) with them.

Anyhow, I hope this is useful information, and hope its usefulness makes up for the lack of brevity.

Best Wishes,

Barry Salkin,
SpR Microbiology.

> -----Original Message-----
> From: McCormick Simon Dr, Consultant, A&E
> [mailto:[log in to unmask]] 
> Sent: 20 September 2007 17:11
> To: [log in to unmask]
> Subject: Re: bat bites
> 
> Rabies shot and a stake through the heart.
>  
> 
>    _____  
> 
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of Scott, Charles
> Sent: 20 September 2007 16:40
> To: [log in to unmask]
> Subject: bat bites
>  
> Could the list enlighten me about the proper treatment of a bite from a
> British pipistrelle bat.    This cropped up recently and we have been told
> (retrospectively) by our microbiologists that any bite patient should have
> rabies prophylaxis, as should her partner who "sucked out the wound".   The
> DEFRA  website sits a little on the fence but probably recommends
> immunisation "in case".
>  
> http://www.defra.gov.uk/animalh/diseases/notifiable/rabies/handlers.htm