Arkansas Hospital Association March 8, 2023 - Laura K. Rothfeldt, DVM, Dipl. ACVPM State Public Health Veterinarian
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Arkansas Hospital Association
March 8, 2023
Laura K. Rothfeldt, DVM, Dipl. ACVPM
State Public Health Veterinarian
Objectives 1. Describe the epidemiology of the rabies virus in the US and around the world. 2. Identify the two animal reservoirs of rabies in Arkansas. 3. Discuss strategies for prevention and control of rabies in the US, including animal bite management procedures.
What is Rabies?
Virus in the brain
All mammals susceptible, but only certain species are reservoirs
Different strains (variants) of the virus identified in lab
Nearly 100% fatal, but also 100% vaccine-preventable
The Good and the Bad
Bad News :(
Very high case-fatality rate of any infectious disease
with long incubation
Good News :)
Limited transmission routes (saliva)
Preventable with pre-exposure and timely post-
exposure prophylaxis
medical urgency, not emergency!
How Do You Get Rabies?
Did sufficient contact occur to allow the transmission of rabies virus?
Bite from rabid animal
• Non-bite exposure to saliva or CSF:
• mucous membranes (eyes, nose, mouth), or
• open, fresh wound
• Organ transplantations
Incubation vs. Infectious
weeks to
months! • Dose of virus?
• Site of
infection?
• Type of
animal?
Symptoms in Animals
Dumb
o Depression
o Lethargy
o Dropped jaw, difficulty swallowing
o Seemingly overly tame disposition
Furious
o Aggressive
o Self-mutilation
o Behavioral changes
The Lancet Infectious Diseases 2002 2, 327-343DOI: (10.1016/S1473-3099(02)00287-6)
Copyright © 2002 Elsevier Ltd Terms and Conditions
Global Rabies https://www.who.int/news-room/fact-sheets/detail/rabies (photo credit: Daniel Stewart)
Rabies in the World
59,000* people die of rabies yearly (primarily children)
Mostly in Asia and Africa
Dog variant rabies
No vaccines or drugs available
*Hampson K, Coudeville L, Lembo T, et al.; Global Alliance for Rabies Control Partners for Rabies Prevention. Estimating the global burden of endemic canine rabies.
PLoS Negl Trop Dis 2015;9:e0003709. https://doi.org/10.1371/journal.pntd.0003709 PMID:25881058
Distribution of the global rabies burden in 2015:
A: human rabies deaths
B: per capita death rates (per 100,000 persons)
C: expenditure on dog vaccination (per 100,000 persons)
Countries shaded in grey are free from canine rabies.
Vaccination of 70% of the local canine population is
now recognized as the single most effective method
to prevent human deaths due to rabies.
Hampson K et al. Global Alliance for Rabies Control Partners for Rabies Prevention.
PLoS Negl Trop Dis. 2015 Apr 16;9(4).Veterinarians play an essential role in human rabies
prevention.
Rabies cases in humans and domestic animals — US, 1938–2018
Pieracci et al. MMWR Morb Mortal Wkly Rep. 2019;68(23):524-528.Rabies in United States
https://ij-healthgeographics.biomedcentral.com/articles/10.1186/1476-072X-5-47Rabies Virus Variants (RVV) in U.S. U.S. o Insectivorous bats (nearly all human cases) o Carnivores (skunks, foxes, raccoons, coyotes) o Canine (dog) type eliminated in 2007!
Distribution of
rabies reservoirs in
the United States,
including Puerto
Rico, from 2016
through 2020.
Distribution of major rabies virus variants (RVVs) among mesocarnivores in the US, including Puerto Rico, from 2016 through 2020. Darker shading indicates counties with confirmed animal
rabies cases in the past 5 years; lighter shading represents counties bordering enzootic counties without animal rabies cases that did not satisfy criteria for adequate surveillance. Small
nonenzootic areas with no rabies cases reported in the past 15 years are shaded if they are in the vicinity of known-enzootic counties and do not satisfy criteria for adequate surveillance. ARC
FX = Arctic fox RVV. AZ FX = Arizona fox RVV. CA SK = California skunk RVV. E RC = Eastern raccoon RVV. MG = Mongoose RVV. NC SK = North central skunk RVV. SC SK = South central skunk RVV.Spillover Wildlife reservoirs maintain rabies Infection transmitted among wildlife and spread to other species
Human Rabies in U.S.
Fox Unknown
Raccoon
30,000 to 60,000 potential exposures per year* 7%
2% 2%
11
Average 1 to 3 cases per year
5 rabies deaths in the U.S. in 2021 Dog
26%
4 Bat
63%
Dog exposures all outside of US:
Ghana
15 36
Philippines: 4
Puerto Rico: 2 (Mongoose)
Haiti: 2
India: 2 Human rabies cases
El Salvador in the U.S.
Guatemala 2000–2021
Brazil
Afghanistan
JAVMA • Vol 260 • No. 10 • May 5, 2022• https://www.cdc.gov/mmwr/volumes/71/wr/mm7101a5.htm • https://www.cdc.gov/mmwr/volumes/71/wr/mm7149a2.htm
Rabies in Arkansas
Arkansas variants are skunk and bat but any
mammal is susceptible!Positive Rabid Animals in Arkansas by Species
1990–2021
2% 1% 2% 0% Bat
Non-Reservoirs 1% 3% 0%
0% Skunk
• Dog 54 21% Raccoon
• Cat 38 367 Fox
• Cattle 29
• Fox 11 Dog
• Equine 10 Cat
• Donkey 1
Equine
• Ferret 1
• Goat 2 Cattle
• Raccoon 0 70% Goat
1199
FerretPositive Rabid Animals in Arkansas by Year
1990–2021
160
140
120
100
80
60
40
20
0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Skunk Bat Cat Cattle Dog Fox Horse Other2020 2021
Animal Rabies 2021 12/31/2021
Benton Carroll Fulton Randolph Clay
Boone Baxter
Marion
Sharp
Izard Greene
1 Lawrence
Washington Madison
Newton Searcy Stone
2 Mississippi
Independence Craighead
1 1 2
Crawford Franklin Johnson Van Buren 2 Poinsett
Pope Jackson
Cleburne
Conway 1
Cross
Logan 1 White Crittenden
Sebastian 1
Faulkner Woodruff
1
Yell 1 St. Francis
Perry
Scott
3 Prairie Lee
Pulaski Lonoke
Garland 1
Monroe
Montgomery
Saline
Polk 1 Phillips
1
Hot Spring Arkansas
Grant
Pike Jefferson
Bat = 9
Sevier
Howard
1
Clark
Dallas
Cat = 0
1
Dog = 0
Cleveland Lincoln
Desha
Little River Hempstead Nevada 1 Skunk = 15
Ouachita
Calhoun
Drew
Total = 24
Bradley
Miller 1 1 positive
Lafayette
Columbia Ashley Chicot 2 positives
Union
3 positives
4 positives
5 or more positives2022 2023
Raccoons Tested for Rabies in Arkansas, 2009‒2021
80 Total Tested: 703 Rabies Negative
70
Total Positive: 0 Rabies Positive
Number of Raccoons Submitted
Not Tested
60
50
40
30
20
10
0
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Year of SubmissionRaccoon Rabies in AR? Test average of 55 raccoons/year Single positive in 1992 Likely false positive? No raccoon variant in AR!
Which Animals Pose a Risk?
Skunk*
Only if bizarre behavior!
Bat* Opossum
Dog Squirrels
Cat Rabbits/hares
Livestock (cattle, horse, sheep/goat) Chipmunks
Pet rats, hamsters, gerbils
Other carnivores (fox, coyote, ferret)
Other small rodents
Raccoon (AR?)
Large rodents (groundhog)Arkansas Rabies Control Act
Act 159 of 2009
First rabies law in AR in 1945
Rabies Control Act in 1968
Act 159 of 2009 in effect January 1, 2010§ 20-19-302 Definitions
• Owner: any person who:
• (A) Has a right of property in a dog or cat or other animal;
• (B) Keeps, harbors, cares for, or acts as the custodian of a dog or cat or other animal; or
• (C) Knowingly permits a dog or cat or other animal to remain on or about any premises
occupied by him or her
The definition of a
stray has different
meanings to
different people!Vaccination for dogs and cats
§ 20-19-305
required
All dogs, cats, and other animals shall be vaccinated
against rabies as required by the State Board of
Health
"Vaccination against rabies" means the injection,
subcutaneously or otherwise, of antirabic vaccine, as
approved by the United States Department of Agriculture or
the State Board of Health and administered by a licensed
veterinarian or agent of the Department of Health.
Waivers or exemptions not currently permitted
Titers do NOT replace a current rabies vaccination
Owners may refuse vaccination
Pets considered unvaccinated in exposure/bite situations will
be required to be vaccinated according to the situationSECTION II Vaccinations All dogs/cats must be vaccinated by 4 mo. age Must be given by licensed veterinarian (not vet tech, feed store/OTC vaccines) 1. If initial rabies vaccine, revaccinate < 1 year later 2. Booster every 1-3 years depending on vaccine used Extra-label use in wild animals (raccoons, skunks, coyotes) or wolfdog hybrids is ‘allowed’ Inform owner extra-label use, may not be protective
§ 20-19-306 Illegal acts when person
bitten
Unlawful for anyone with knowledge of bite to refuse to notify
health authorities promptly (person bitten, family, physician,
veterinarian)
Unlawful for owner of the dog/cat to sell, give away, transfer,
transport to another area, or otherwise dispose if known to have
bitten a person until released by health authorities
Unlawful for owner to refuse or fail to comply with the written or
printed instructions of the health authorities
By law, animal bites MUST be reported!Animal Bite Reporting
Animal control officer, law enforcement,
EHS, or Healthcare Provider
Take bite report
Get all patient and animal information
Form available from ADH website
Send completed forms to Local Health Unit
Follow-up and find out:
Where is the animal?
Vaccination history of animal?
Medical care for bite?
Quarantine or euthanasia?Fax or email to:
1. County Health Unit
(https://www.healthy.arkansas.gov/health-
units)
2. ADH Zoonotics Section 501-280-4431 (fax)
(adh.zoonotic@Arkansas.gov)
https://www.healthy.arkansas.gov/images/uploads/pdf/AnimalBiteInvestigationForm.pdfWas the Animal Rabid?
• Was the biting animal a rabies vector?
• If yes, then rabies testing is always recommended, regardless of rabies vaccination
status. There is no established quarantine period for these species.
• Is the animal available for quarantine and/or monitoring?
• If yes, and the animal is not showing compatible symptoms, then quarantine and/or
monitoring could be recommended in lieu of post-mortem rabies testing.
• Is the animal not available to be monitored, or do the circumstances
indicate an increased probability of rabies being a risk?
• If yes, then plans should be made to process the specimen (decapitate, chilled
storage) in order to submit to the public health lab for rabies testing.BEWARE
Dog under
QUARANTINE for RABIES
by order of
AR Department of Health
Effective from MM/DD/YY until MM/DD/YYRabies Quarantines
Two different kinds of “quarantines” to consider
Dog/Cat/Ferret is bitten by a rabid animal Dog/Cat/Ferret bites a human
Incubation period (45 days or 4 months Infectious period (10 days)
depending on vaccination and booster status) Was the animal shedding rabies virus
Will the animal develop rabies disease during the in saliva at time of bite (could the
incubation period? animal have transmitted disease)?
http://nasphv.org/Documents/NASPHVRabiesCompendium.pdfIncubation Period Infectious Period
Infectious Period
Why 10 Day Confinement or Bite Hold?
Virus in brain before salivary glands (infectious period)
Occurs at end of incubation period (weeks to months)
Brain disease progressing and dog/cat will begin to show clinical
signs of rabies (and die) within 4-6 days
Abundance of
CautionOther Animal Bite Same as for dog/cat bites, but… oWhere is animal — available for testing? oMedical care for bite oAssess risk for rabies and need for PEP
What about bats?
Bats: very small, < 20 grams, tiny needle-like teeth
Bat bite is unlikely to send anyone to the ER (trivial bite)!
Rabies-positive red bat (Lasuirus borealis) Big Brown Bat (Eptesicus fuscus) Eastern pipistrelle and Silver-haired batBat Bites in Humans
What to do?
Catch the bat and TEST it for rabies
Possible exposures without known physical contact:
bat in a room with an unattended child
sleeping person awakes to find a bat in room
Deep sleeper?
Impaired by drugs, alcohol, or cognitive dysfunction?
If the bat can’t be tested and contact
cannot be ruled out, then the rabies post-
exposure series should be given!Shipment to laboratory of head of animal
§ 20-19-308
suspected of being rabid
Any person causing the death of
an animal suspected of being
rabid shall ensure the head of the
animal is sent to the county
health unit of the county in which
the animal was killedDirect Fluorescent Antibody
(DFA Test)
“Gold Standard”What about newer tests?
Real-time RT-PCR “LN34”
no false negatives, fewer false positive, and fewer inconclusive results
tissue that is fresh, frozen, decomposed, or that has been fixed in blocks of paraffin to
inactivate the virus
DFA (current Gold Standard)
interpreted by laboratory workers with special skills, extensive training, and a specific type of
microscope
Experts estimate that rabies testing, prevention, and control cost $245 to $510 million annually in
the United States.Specimen Shipment for Rabies Testing
Rabies buckets/boxes (Local Health Unit [LHU] in every county)
DO NOT submit live animals.
Bats may be submitted intact; only submit the head or brain tissue for all other species.
Refrigerate up to 72 hours; ship specimens on cold packs
Freezing delays results (specimen must be thawed)
Fill out submission form (online)
submit printed summary page or include the survey number with the specimen
Courier weekdays to PH lab (free)
Ship via UPS/FedEx, overnight delivery (expensive); ship in compliance with DOT shipping regulations for Category B packages.
https://www.healthy.arkansas.gov/programs-services/topics/rabies-testingReporting Results Laboratory calls submitter only with all negative results Submitter is responsible for calling anyone else involved! SPHV or zoonotic epidemiologist notifies all involved with positive results Investigates incident & conducts risk assessments for rabies PEP Advises what law mandates and Rabies Compendium recommends should happen Utilizes Animal Control Officer or Law Enforcement when necessary
Post Exposure Prophylaxis (PEP)
If animal cannot be If animal tests
tested and is suspect positive for rabies
Joseph Meister 1885Animal Bite Wound Treatment
*Wash* the wound with soap and water,
irrigate with virucidal solution
Contact healthcare provider any time the skin is
broken
oRabies prevention = Post-Exposure Prophylaxis (PEP)
o ADH State Public Health Vet consultation (24/7)
oTetanus booster
oAntibioticsRisk Assessment for Rabies PEP Location in state? Location on body? Type of animal? oSeverity? oReservoir species? Circumstances? oDomestic or wild animal? oProvoked? Type of exposure? Timely test results? oBite, scratch, head removal?
Human Rabies PEP 1. Wound cleansing 2. Human Rabies Immune Globulin (HRIG) 3. Rabies Vaccine series PEP is a medical urgency, NOT a medical emergency!
Rabies PEP ($$$)
1. Human Rabies Immune Globulin (HRIG)
Day 0, dosed by weight (20 IU/Kg), infused around the bite
Day 0 is start date of
2. Rabies Vaccine (#4 doses) PEP, NOT date of bite!
Given in deltoid or antero-lateral thigh (not gluteals)
Days 0, 3, 7, and 14
*5th dose for immune-compromised persons on day 28Pre-exposure Prophylaxis (PrEP) For high-risk groups Rabies Vaccine (#2 doses) oReduced from 3 doses in 2022 oDays 0 and 7 o‘Primed’ for life (modern cell culture) oTest titers according to risk category (booster if low) If exposed to rabies: oNO HRIG oVaccinate with 2 doses: days 0 and 3
Animal Bites
Dog and Cat Bites
• ~4.5 million persons are bitten by dogs each year
• ~800,000 receive medical attention (1 in 5)
• ~ 316,000 are treated in the ER; ~ 9,500 are hospitalized
• Dogs (90%) > Cats (6%)
• 3-5% of dog bites become infected
• 20-50% of cat bites become infected
• Primary victims are children
https://www.aafp.org/afp/2014/0815/p239.html• Dog bites account for 1% of injury-related ER visits in US
• Estimated $53.9 million in costs per year
• 10 to 20 animal bite–related deaths, mostly from dogs, annually.
• Insurance companies paid $530.8 million for dog bite liability claims
in 2014
• Dog bites accounted for more than a third of all homeowners
insurance liability claims
• Average cost per dog bite claim was up to $32,072 in 2014,
compared with $27,862 in 2013, and $24,840 in 2009
http://www.insurancejournal.com/news/national/2015/05/15/368180.htmMore Dog Bite Statistics
~2/3 bites occurred on or near victim’s property, and most
victims knew dog
Bite Fatalities (2005 to 2017)
• ~30 human deaths per year in US
• Majority of human deaths caused by male dogs, not neutered
• At least 30 different breeds of dogs have been involved in dog-
bite-related fatalities in the U.S.
• 48% of fatalities were ≤9 years old (children ages 0-2 accounted
for 27%)
• 54% of fatalities were from family dogs
• 25% occurred off of dog owner’s property
• 21% of fatal dog maulings resulted in criminal charges
https://www.dogsbite.org/reports/13-years-us-dog-bite-fatalities-2005-2017-dogsbite.pdf• The Arkansas Department of
Health does NOT administer
rabies PEP!
• Patients must seek care
through many of the larger
Emergency Departments.*
• Unfortunately, access can be
hindered by location in the
state and insurance status of
the patient.
*Some pharmacies have rabies vaccine on
formulary, but might only administer for
pre-exposure situations, not post-exposure
bites/scratches.ADH Rabies Program ADH call line available 24/7 to the public, HCP’s, DVM’s, public health, animal control, and law enforcement for animal bite rabies risk assessments. 501-280-4136 (office) 501-661-2000 (main ADH) 800-633-1735 (24/7—ADH emergency call center)
Laura Rothfeldt, DVM, DACVPM
State Public Health Veterinarian
Zoonotic Disease Section
Arkansas Department of Health
office: 501-280-4136 • mobile: 501-681-2277
Laura.Rothfeldt@arkansas.gov
www.Healthy.Arkansas.gov
The images, written excerpts, and videos included in this presentation are for
educational purposes only and may be subject to copyright.
Depiction of a specific product does not imply endorsement of said product by ADHAdditional Resources
• Rabies ACIP Vaccine Recommendations: https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/rabies.html
• NASPHV Compendium of Animal Rabies Prevention and Control, 2016: http://www.nasphv.org/Documents/RabiesCompendium.pdf
• Arkansas Department of Health. Rabies Information for Healthcare Providers:
• https://www.healthy.arkansas.gov/programs-services/topics/information-for-healthcare-professionals
• Centers for Disease Control and Prevention Rabies: www.CDC.gov/rabies
• Global Alliance for Rabies Control: https://rabiesalliance.org/world-rabies-day
• World Health Organization (WHO) Rabies Overview: https://www.who.int/health-topics/rabies#tab=tab_1
• WHO Rabies Map: https://apps.who.int/neglected_diseases/ntddata/rabies/rabies.html
• Journal of American Veterinary Medical Association Rabies Surveillance Report: https://avmajournals.avma.org/view/journals/javma/260/10/javma.22.03.0112.xml
• Hampson K, Coudeville L, Lembo T, et al.; Global Alliance for Rabies Control Partners for Rabies Prevention. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis
2015;9:e0003709. https://doi.org/10.1371/journal.pntd.0003709 PMID:25881058
• Wallace RM, Gilbert A, Slate D, Chipman R, Singh A, et al. (2014) Right Place, Wrong Species: A 20-Year Review of Rabies Virus Cross Species Transmission among Terrestrial Mammals in the United States. PLOS
ONE 9(10): e107539. https://doi.org/10.1371/journal.pone.0107539
• Whitehouse ER, Person MK, Brown CM, Slavinski S, Rao AK, Blanton JD. Evaluating surveillance for and estimating administration of rabies postexposure prophylaxis in the United States, 2012–2018. PLoS Negl
Trop Dis 2021;15:e0009878. https://doi.org/10.1371/journal.pntd.0009878; PMID:34695115
• Kunkel A, Minhaj FS, Whitehill F, et al. Notes from the Field: Three Human Rabies Deaths Attributed to Bat Exposures — United States, August 2021. MMWR Morb Mortal Wkly Rep 2022;71:31–32. DOI:
http://dx.doi.org/10.15585/mmwr.mm7101a5
• Pieracci EG, Pearson CM, Wallace RM, et al. Vital Signs: Trends in Human Rabies Deaths and Exposures — United States, 1938–2018. MMWR Morb Mortal Wkly Rep 2019;68:524–528.
DOI: http://dx.doi.org/10.15585/mmwr.mm6823e1You can also read
