Rabies Control for EHS Training

Rabies: Overview of Epidemiology, Exposure Response and Law Julia Murphy, DVM, MS, DACVPM State Public Health Veterinarian Office of Epidemiology Virginia Department of Health 2017 Rabies History Rabies History A recognized disease as early as 2300 BC

Aristotle wrote about rabies in 322 BC Saliva of rabid dogs was recognized as venomous in the 1st century AD Rabies History, US First documented case in US Virginia, 1753 Colonial

times-1950s Dogs highest vector risk 1960s-today Wildlife greatest reservoir Rabies History, Virginia Raccoon

Noticed in FL in mid 50s Spread to VA in 1970s Seen everywhere but sw VA Skunk rabies: rabies Present in low levels in sw VA since 1960s Why rabies? ~20,000

40,000 people undergo rabies prophylaxis each year in US Infection is almost always fatal Public health costs (detection, prevention, control) > $300,000,000 annually in U.S. Rabies is endemic in Virginia Rabies: Presentation outline Rabies - Outline Virus Disease

and diagnosis Variants Animal epidemiology US and VA Human epidemiology US and VA Rabies control and exposure response Rabies laws in the Code of Virginia Rabies: Virus characteristics Rabies Virus

Only affects mammals Inactivated by drying, high temperatures, sunlight, most disinfectants Survives freezing Found in wet saliva and central nervous system tissue of infected mammals Image courtesy of CDC Rabies: Disease and

diagnosis Rabies Virus - Transmission Most commonly through the bite and viruscontaining saliva of an infected animal Virus can not enter intact skin Other possible routes Contamination of mucous membranes

Scratches - only if contaminated with wet saliva or CNS material Aerosol Transplantation Rabies virus-Pathogenesis Virus enters the body Virus enters NM junctions Travels via peripheral nerves to spinal cord Then to brain stem and forebrain Rabies signs and symptoms in

animals Clinical presentation is variable Early vague, nonspecific Behavioral more or less aggressive, vocalization Physical appetite loss, paralysis, seizures, coma, death Behavior or physical signs or symptoms that are clearly abnormal Rabies-Symptoms in Humans Initial

clinical symptoms include anxiety, headache, mild fever, irritation at bite site Progresses to muscle spasms, difficulty swallowing, hydrophobia Clinical course is typically short Rabies Diagnosis in Animals Postmortem Samples test should be refrigerated and

submitted to the state laboratory Results available in about 24 hours Results reported to local health department Image courtesy of CDC How is testing performed? No

accurate test exists for examining live non-primate animals for rabies infection Animal necropsy of optimal parts: Brain stem or medulla oblongata, Cerebellum, Hippocampus or Ammons Horn Direct Fluorescent Antibody Test for Rabies Virus May be used on fresh or decomposed tissue

Produces sensitive and rapid results Considered the most reliable of all available technologies Daily quality control steps assure accuracy Rabies virus variants

Rabies virus variants, US Raccoon Any variant can infect any species Fox 3 variants Skunk

3 variants Bat Multiple variants Mongoose Majority of animals diagnosed with the

raccoon variant each year Rabies Virus - Variants Associated with certain animal species Associated with certain geographic areas (except bats) Spillover to other species Vaccines protect against all variants Distribution of Major Terrestrial Reservoirs of Rabies

in the United States and Puerto Rico, 2013 Rabies Virus Variants, VA Two terrestrial wildlife rabies variants raccoon and skunk Spillover to other wild and domestic animals Raccoon endemic in most areas with cycling Skunk confined to southwest VA

Multiple bat variants Occasional spillover Rabies: Animal epidemiology and exposure risk Dogs and cats The time between when a dog or cat is

exposed to rabies and when that animal will show signs of disease has been studied with incubation periods over 4 months rarely reported Typical incubation period is 1-2 months Dogs, cats, ferrets The time between when a dog, cat or ferret starts shedding virus in its saliva and when that animal starts acting sick and then dies is also well established

Typically a dog, cat or ferret will start shedding the virus in its saliva the same day it starts acting sick and will only live for a couple of days after that (may live as long as 8 days) Rabies Shedding-Other Animals For animals other than dogs, cats and ferrets, we do not know a definitive time period between when they start shedding the virus and when they start acting sick

This is why the only definitive observation times we have are for dogs, cats and ferrets Rabies risk of transmission by animal type High risk

Low risk Carnivores (raccoons, skunks, foxes) Large rodents (e.g., groundhogs in raccoon variant areas) Opossums (in raccoon variant endemic areas) Bats Small rodents (e.g., squirrels, chipmunks) Rabbits, hares

Evaluate circumstances Exotic animals/hybrids Livestock Rabies Risk by Animal Type For those animals for which no observation time has been established and do not fit into either a distinctly high risk or low risk category, the response is based on consideration of a number of

factors including the scientific family of the animal, circumstances of exposure, how the animal is housed and/or health of animal. Rabies - Animal Epidemiology Photo courtesy of DGIF Rabies - Animal Epidemiology Rabies Wild Animal Epidemiology, US Photos courtesy of CDC

Wild Animal Rabies Epidemiology, US Wildlife have accounted for > 90% of reported rabid animals in the United States since 1980 Raccoons, skunks, foxes and bats make up the bulk of rabid animals reported each year Raccoons are the most commonly diagnosed species in Virginia Photo courtesy of DGIF

Rabies - Domestic Animal Epidemiology, US Domestic Animal Rabies Epidemiology, US Domestic animals typically make up less than 10% of the total number of animals diagnosed with rabies each year in the US Cats are the domestic animal most commonly diagnosed with rabies Rabies Animal Epidemiology,

Virginia Two terrestrial wildlife rabies variants raccoon and skunk Spillover to other wild and domestic animals Raccoon endemic in most areas with cycling Skunk confined to southwest VA Multiple

bat variants Occasional spillover Animal Rabies Statistics VA, 2014-2016* Animal 2014 2015 2016

Raccoon 236 263 158 Skunk 162 121 90

Fox 45 41 27 Bat 23 15

16 Dog 1 5 4 Cat 28 38

25 Cow 12 20 12 Horse 0

3 0 *Statistics may also include alpaca, bobcat, coyote, deer, donkey, goat, groundhog, opossum, pig and other mammals Rabies: Human epidemiology Human Rabies Epidemiology, US 34 cases, 200313 20 infected with a bat variant

Some with exact exposure unknown Foreign travel to countries where domestic animal rabies is more common is also a risk factor Human Rabies Epidemiology, Virginia Cases 1953 veterinary hospital worker

1998 prisoner in work program Unknown exposure Pipistrel/silver-haired bat variant 2003 office worker

Unknown exposure Unknown exposure Raccoon variant 2009 traveler to India Exposed to dog Image courtesy of CDC

Rabies: Control and exposure response Rabies Control Domestic Animals and Humans Animal and human vaccination Animal control Pre- and postexposure management

Rabies Control Domestic Animal Vaccination Virginia code requires dogs and cats to be vaccinated by 4 months of age Booster dose given 1 year after initial vaccination Thereafter, should vaccinate every year or every 3 years, depending on vaccine type Encourage use of 3 year vaccine Rabies Control Domestic Animal

Vaccination Virginia code requires vaccine administration by currently licensed veterinarian or licensed veterinary technician under direct supervision Veterinarians must practice in a licensed facility Exception rabies clinics outside licensed facility Require the approval by the appropriate local health department and governing body Governing body shall ensure a clinic is conducted at least once every 2 years

Rabies Control Human What constitutes an exposure? Any bite, scratch, or other situation where saliva or central nervous system tissue from a potentially rabid animal enters an open fresh wound or contacts a mucous membrane by entering the eye, mouth, or nose Photo courtesy of Grace Woo Rabies Control Human

Bat Exposure Small bites; may go unrecognized Always ideal to test bat if available PEP indicated in response to: 1. Known bite 2. Direct contact and bite cannot be ruled out 3. Situations where exposure may have gone unrecognized like bat found in the same room as a sleeping or mentally impaired or very young person Rabies Control-Human

Scratches: A scratch should be evaluated like any other open wound, i.e. did saliva or some other virus containing material (cerebral spinal fluid, brain) contaminate the wound while it was fresh. A scratch in and of itself is not an exposure unless the paws were soaked with saliva, e.g., cat is salivating/drooling profusely or paws are visibly wet. Rabies Control Domestic Animals What

constitutes an exposure? Any circumstance where saliva or central nervous system tissue from a potentially rabid animal did have or could have had direct contact with mucous membranes or a break in the skin of a domestic animal Note: The actual witnessing of a bite or attack by a potentially rabid animal is not required for an exposure to have occurred, however, a suspect needs to be witness in close proximity.

Rabies Control Guidelines for Humans Human exposed to a dog, cat, or ferret Any dog, cat, or ferret (vaccinated or unvaccinated) that bites a person must be confined for 10 days observation

Veterinary evaluation at first sign of illness If thought to be rabies, euthanize and test Do not vaccinate during confinement Rabies Control Guidelines for Humans Pre exposure series High risk occupations: DVMs, ACOs, LVTs

Antibody measurement every 2 years Boosters if exposed or low titer (routine boosters not recommended) Should not receive RIG Post exposure series (for those with no prior vaccination) RIG plus 4 vaccinations RIG plus 5 vaccinations in some pts. Image courtesy of CDC

Domestic Animal Exposure Confinement House animal in a building, pen, or other escapeproof method or enclosure Do not remove animal unless on leash and under control of responsible adult Owner should notify Health Department at first sign of illness and take to veterinarian

Domestic Animal Exposure Strict isolation House animal in a kennel at a veterinary hospital, animal control facility, commercial boarding establishment, or pen at home Pen design should prevent direct contact between animal and human or other animal

Pen design should allow for feeding, watering, cleaning (see example in Guidelines) District Health Director or designee should approve pen Domestic Animal Exposure Vaccinated dog, cat, or ferret exposed to proven or suspected rabid animal Should receive immediate booster of vaccine Confine for 45 days observation Veterinary evaluation at first sign of illness If thought to be rabies,

euthanize and test Domestic Animal Exposure Unvaccinated dog, cat, or ferret exposed to proven or suspected rabid animal

If available, test exposing animal If exposing animal unavailable or tests positive, euthanasia or 4 months strict isolation for dogs and cats, 6 months for ferrets (current national guidelines) Veterinary evaluation at first sign of illness If thought to be rabies, euthanize and test Vaccinate exposed animal before release from isolation; ideal to vaccinate upon entry Rabies Control Guidelines for Domestic Animal Exposure Dog, cat, or ferret with expired vaccination

exposed to proven or suspected rabid animal Immediate booster to exposed animal (unless euthanized) If available, test exposing animal Assessed on case by case basis Often treated dogs and cats using the same protocol for currently vaccinated animals particularly if the exposed animal is not immunocompromised

Domestic Animal Exposure Livestock response similar to dog, cat and ferret if exposed to high risk species for rabies or carnivore confirmed with rabies If the only rabid animal associated with a herd or flock is an herbivore, monitoring for a period of 30 days for additional rabid animals in the herd or flock should be sufficient Herbivores are not efficient transmitters

Monitoring for exposures that occurred when index case was exposed Rabies related laws in Virginia Rabies related laws Code of Virginia sections: 3.2-6521. Rabies inoculation of companion animals 3.2-6522. Rabid animals 3.2-6562.1 Rabies responsibility plan

18.2-313.1 Withholding information about a possibly rabid animal 54.1-3812. Release of records www.virginia.gov to access Code of Virginia Rabies regulations Rabies related Code sections modified and one section added as part of the 2010 General Assembly Vaccine exemptions The Board of Health, shall adopt regulations to implement the provisions of this act. Such

regulations shall include a model plan that may be used by localities to comply with the requirements of 3.2-6562.1 of this act. Rabies Regulations Virginia Administrative Code http://law.lis.virginia.gov/admincode/title12/agency 5/chapter105 Definitions Rabies

Clinic Responsibilities Model Plan Exemption process Guidance document developed Standard application Rabies: Basic messages for the general public Rabies Control Messages for the Public

Keep rabies vaccinations up-to-date on dogs, cats, and ferrets Supervise pets so they do not come into contact with wild animals Call animal control to remove strays Teach children never to handle unfamiliar animals Rabies Control Messages for the Public Enjoy wild animals from afar

Never adopt wild animals Do not encourage wild animals to come close to/into your house Avoid leaving pet food outside Keep trash inside or use lids on trash Do not relocate wildlife Call DGIF or licensed rehabber for support Rabies Control

Messages for the Public If youve been bitten Decrease the chance of infection by washing the wound with soap and water Capture the animal if this can be done SAFELY Call animal control or local hd Rabies Campaigns

Rabies Resources www.vdh.virginia.gov Rabies Control page http://www.vdh.virginia.gov/environmental-epidemiology/rabies-control/ Disease Control Manual Rabies chapter www.cdc.gov/rabies www.nasphv.gov

Code of Virginia http://lis.virginia.gov/000/src.htm

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