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College of Public Health, Medical and Veterinary Sciences
M. Young, B. McCall (2010)
Potential exposure to Australian bat lyssavirus in south east Queensland: what has changed in 12 years?Communicable diseases intelligence quarterly report, 34 3
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A ustralian Bat Lyssavirus (ABLV) is a member of the Lyssavirus genus in the family Rhabdoviridae . ABLV has been found in both flying fox and insectivorous bat species. 1 Testing has demonstrated ABLV is widely distributed in wild bat populations in Australia. 2 It is estimated about 1% of bats in the wild have ABLV, but about 30% of bats found sick or injured have had ABLV. 3 Humans most commonly come into contact with bats that are sick, injured or orphaned, placing vets and animal handlers at high risk of exposure to ABLV. 2 The mode of transmission for ABLV is presumably similar to rabies virus, i.e. by the virus‐laden saliva of an infected animal introduced by a bite or scratch, or by contamination of mucous membranes or broken skin. 4 It is assumed that all Australian bat species have the potential to carry and transmit ABLV. 4 Three human cases of ABLV have been reported and all developed fatal encephalitis after being bitten or scratched by bats. 4 In 1996, a 39‐year‐old woman died about 50 days after being bitten by an insectivorous bat and, in 1998, a 37‐year‐old woman died 27 months after being bitten by a bat. 5,6 In February 2013, an 8‐year‐old boy died some two months after a bat bite or scratch. 7,8 Vaccination against rabies virus is effective against infection with ABLV, 5 but its administration can be complex, costly and time‐consuming. Pre‐exposure vaccination with rabies vaccine is recommended for people whose work or recreational activities place them at increased risk of being bitten or scratched by bats. 4 Pre‐exposure vaccination with rabies vaccine consists of three doses over 28 days, while post‐exposure prophylaxis for vaccinated people is another two doses. 4 For unvaccinated people, the recommended post‐exposure prophylaxis is four doses of rabies vaccine plus a dose of Human Rabies Immunoglobulin (HRIG) into the site of the bite or scratch. 2 A Queensland study in the late 1990s found that volunteer animal handlers accounted for 39% of bat exposures, professional animal handlers for 14%, community members who intentionally handled bats for 31% and community members with contacts initiated by bats for 4%. 9 In a south‐east Queensland study between 1996 and 2008, 52% of people potentially exposed were members of the public who attempted to rescue entrapped bats. This study reported an average annual notification rate of potential exposure to ABLV of 3.5 per 100,000 population. 10,11 The Australian Government is quite clear in its national guidelines for rabies and ABLV that “only appropriately vaccinated and trained people should handle bats”. 4 Managing the public health risk Potential exposure to ABLV is a notifiable condition in Queensland, where exposures to bats are managed by local public health units. 9,12 Communicable diseases staff investigate bat exposures, organise pre‐ and post‐exposure prophylaxis, and deliver health education messages about not handling bats. 1 In 2013, Queensland Health was notified of 494 people exposed to a bat bite or scratch. 13 In mid‐2012, the Cairns Public Health Unit (CPHU) was notified of two people – one a volunteer worker, one a member of the public – who had been bitten or scratched by bats at a single wildlife facility in North Queensland. The unit initiated an investigation, with the aim of minimising any further risk to public health posed by the facility. This was part of a multi‐agency response to the notification; the Queensland Department of Environment and Resource Management investigated the facility's authority to keep bats, while Workplace Health and Safety Queensland investigated risks to workers at the facility. While these investigations were under way, the Cairns Public Health Unit put steps in place to ensure the facility did not pose a continuing risk to staff, researchers, volunteers, students or visitors to the facility. Queensland's Public Health Act 2005 (the Act) provides safeguards necessary to by placing requirements on state and local governments, healthcare providers and the community. Under the Act, animals likely to have been exposed to an infectious condition are designated as a local government public health risk. 14 The State Government and a local government may agree to administer the Act in partnership 15 and, in this instance, Cairns Regional Council and the CPHU entered a partnership agreement around the enforcement of the Act, enabling officers to promptly address the risk at the facility. Co‐authors environmental health officer Brad Milligan and public health nurse Juliet Esmonde were among the staff from the CPHU who carried out the investigations of the facility. The wildlife facility gave visitors ‘the opportunity to meet a flying fox’ 16 and at the time of the investigation was home to a resident colony of five bats, which spent time on display in the interpretive centre. The facility is funded in part by the operation of the interpretive centre and through fees from volunteers, interns, students and researchers. 16 CPHU staff visited the facility several times during the course of their investigation and, during one visit, Mr Milligan observed school students returning to the facility holding an injured bat. Investigating health staff noted that the centre's visitors’ book contained comments about visitors handling bats and being scratched by them, and the owner admitted the public were allowed to handle the bats. There were also permanent and temporary staff and volunteers working at the facility who had not been vaccinated against ABLV and the centre had no vaccination policy or records. Communicable disease control staff interviewed the two complainants, who said they had not been given any advice from the facility about the risk of ABLV or about seeking medical attention. They were advised to seek immediate medical attention and receive post‐exposure prophylaxis. The Public Health Act 2005 allows authorised persons to issue public health orders that require the recipient of the order to reduce, control or prevent a public health risk. 15 On 25 July 2012, CPHU's Environmental Health Services issued a public health order to the facility to minimise the risk posed by ABLV infection from bats kept and exhibited there. To remove this public health risk, the facility was required to undertake several activities including: not exhibiting bats; not allowing people to access bats unless they demonstrated a valid ABLV vaccination; and implementing a procedure for response to exposure to bat bites or scratches. The maximum penalty for not complying with the order is $20,000. In response to the public health order, the owner provided details of eight people who may have been exposed to bat bites or scratches; these people were contacted by CPHU and advised to obtain post‐exposure prophylaxis. Queensland Health also sought to contact anyone who had handled bats at the wildlife facility in the previous seven years, since the incubation period of rabies (which is presumably similar to that of ABLV) can range up to several years, even 6.5 years in one case. 17,18 The tracing was carried out by talking to contacts provided by the bat facility, issuing a media release and international health alert, a ministerial statement in parliament, and a communiqué to general practitioners, emergency departments and infectious diseases physicians. Public health nurses also contacted tour operators known to have organised groups of students to visit the facility. The media release, health alert and contact with tour operators yielded a further 10 people with bat exposures, who were advised to seek medical attention and post‐exposure prophylaxis. The 18 people with bat exposures were from several Australian states, North America and Europe. None of them had been advised to seek medical attention at the time they were scratched or bitten. It is the first time a public health order has been issued to protect the public from the risk of Australian Bat Lyssavirus. Since it was issued, the wildlife facility has not been open to the public. The order remains in place to ensure public health risks presented by the facility are effectively managed and Environmental Health Officers visit the facility regularly to ensure the public health order is complied with. Investigations into other bat facilities in North Queensland were undertaken by the Cairns Public Health Unit. No other facilities appeared to pose a similar public health risk. This incident falls under the jurisdiction of several agencies that monitor the health risk to the public, the health and safety risk to workers and the environmental licensing of facilities to keep and display bats. Previous intervention by Queensland Health saw only a short‐term level of compliance: in 2004, health staff organised three people to have post‐exposure prophylaxis after handling bats at the facility and had verbally advised the owner to stop allowing people to handle bats. In February 2014, the owner of the facility was prosecuted by Workplace Health and Safety Queensland for failing to meet his work health and safety duties by allowing members of the public and unvaccinated workers to have contact with bats. The owner was given a 12‐month good behaviour bond and ordered to pay court costs. 19 Discussion Bites, scratches and mucous membrane exposures from all bats should be managed as potential exposures to ABLV. 20 According to current national guidelines, all bat handlers should receive pre‐exposure prophylaxis, while anyone bitten or scratched by a bat should receive post‐exposure prophylaxis. 4 Close collaboration between health, environment and workplace health and safety agencies is required to ensure facilities keeping or exhibiting bats do not pose a health risk to workers, researchers, students, volunteers, carers or visitors. This means all people working with bats (whether employed or volunteer) should be vaccinated against ABLV. Unvaccinated visitors to wildlife facilities, whether hospitals, research or tourist facilities, should be prevented from handling bats. Paterson et al. argue that risk communication about ABLV has not adequately entered into public awareness and there is a need to emphasise the severity of the threat and how to avoid it. 21 A comprehensive, ongoing health promotion campaign would help ensure that key messages continue to be publicised: that bat handlers should wear personal protective equipment and be vaccinated against ABLV; all other people should avoid handling bats; and anyone scratched or bitten by a bat should receive post‐exposure prophylaxis. McCall et al. concluded that public health prevention efforts should focus on the risk to humans when untrained, unvaccinated people attempt to handle bats, rather than simply conveying information about ABLV. 11 A health promotion campaign could reinstate the annual mass media advertising campaign used in North Queensland during bat breeding season and include school‐based education (given the latest victim was a school‐aged boy). This campaign should also ensure that all wildlife facilities with bats that are accessed by the public display resources about the risk of ABLV. Acknowledgements The authors thank Dr Richard Gair and Rebecca Richardson from the Cairns Public Health Unit for their contributions to this article.
Australian and New Zealand Journal of Public Health – Wiley
Published: Jun 1, 2015
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