Vector Control: Rabies, UNC-SPH 1

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Module 2. Rabies Epidemiology and Rabies Prevention and Control

Marilyn Goss Haskell, DVM MPH

NC Certified Rabies Vaccinator Training

Topics

• NC Rabies Epidemiology • Human Rabies Mortality • State Laboratory Public Health Testing

Criteria and Public Health Surveillance • Rabies – reservoirs, high risk vectors;

signs of disease in animals • Incubation and Shedding periods • Animal Control Responsibilities

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Topics (cont’d)

• Rabies Prevention in Humans –Exposure and Transmission –Bat Variant –Pre-exposure prophylaxis –Personal Protection and Behavior –Wound care and reporting

exposures –Post-exposure prophylaxis

• Public Messaging

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Learning Objectives

• Describe the Epidemiology of Rabies in North Carolina, United States and the world (Asia and Africa) and the geographical areas where rabid animals are most likely to occur in our state.

• Describe rabies public health surveillance including the location of written criteria, submission criteria of wild and domestic species of mammals to the NC SLPH and public messaging for rabies incidents.

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Learning Objectives (cont’d) • Discuss the characteristics and prevalence of rabies

including high risk animals that may be reservoirs, clinical and behavioral symptoms that animals may or may not exhibit, the types of body fluids that are infectious and types of exposures (direct, indirect and bat).Discuss the roles and responsibilities of Animal Control.

• Outline rabies prevention measures.

• Describe what rabies post-exposure prophylaxis (PEP) is used for and who should assess people that are exposed for PEP.

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Rabies Epidemiology

6 Source: JAVMA, Vol 243 No. 6, September 15, 2013

Vector Control: Rabies, UNC-SPH 2

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Confirmed Rabid Mammals North Carolina, 1952-2013, n =

11,049

0

100

200

300

400

500

600

700

800

900

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52

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57

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62

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67

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72

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77

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82

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87

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92

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97

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02

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07

20

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Bat Rabies; 1st Identified 1963 Raccoon Rabies; 1st Identified 1991

One human rabies case (ERV*); first NC reported

human rabies since

1955

Source: NC State Laboratory of Public Health Updated January 2014

Human - Last

Reported Canine

Variant case in NC - 1955

*ERV = Eastern Raccoon Variant

Human Rabies Mortality

Worldwide

• Canine Variant overwhelmingly

– ~60,000 deaths per year worldwide

– >99% of human cases

– Asia and Africa mostly

– >50% children < 15 years

• US - past 25 years, a few cases per year

– Bat Variant http://www.who.int/rabies/en/ 9 10 http://slph.ncpublichealth.com/virology-serology/rabies.asp

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Vector Control: Rabies, UNC-SPH 3

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Vector Control: Rabies, UNC-SPH 4

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Vector Control: Rabies, UNC-SPH 5

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Rabies Positive Mammals by Species, NC 2013

n = 380 positive; 4314 tested

Species % Positive by

Species Tested

Dog 0.6

Cat 1.8

Goat 3.1

Cattle 4.5

Bat 2.2

Raccoon 42.6

Fox 47.7

Skunk 63.2

Total % Positive 8.9

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BAT, 28

CAT, 20

COW, 4

DOG, 5

FOX, 62

GOAT, 2 RACCOON, 204

SKUNK, 55

91.8% Wild mammals

Source: NC State Laboratory of Public Health; Updated February 2014

Rabies Vaccinations Required by Law Dogs, Cats and Ferrets

NCGS 130A-185. Vaccination required

(a) Vaccination required. - The owner of an animal listed in this subsection over four months of age shall have the animal vaccinated against rabies.

(1) Cat.

(2) Dog.

(3) Ferret

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Rabies Positive Dogs and Cats, NC, 1991 - 2013 (n = 512)

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15

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1991

1993

1995

1997

1999

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2003

2005

2007

2009

2011

2013

Dog

Cat

VACCINATE YOUR PETS, RABIES KILLS Source: NC State Laboratory of Public Health; Updated January 2014

Vector Control: Rabies, UNC-SPH 7

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Animal Control Responsibilities

• Enforce North Carolina Rabies Laws

(NCGS 130A-184 to 130A-204.)

• Investigate exposures to domestic animals

and humans

• Capture and impound animals

• Implement ten day confinements and six month quarantines

• Submit animal specimens for testing to NC State Laboratory Public Health (SLPH)

What causes rabies?

• RNA virus

• Very tiny, microscopic

• Affinity for Nerves

• Highest Case Fatality Rate

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Incubation and Shedding Periods

Animal exposed to rabies virus

Onset of signs of disease

Incubation period

up to 6 months

Excretion of virus from salivary glands

Shedding period

Death

3-7 days

Appears healthy – non infectious

Incubation:

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A bite introduces the virus …

Incubation:

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The virus starts to move from the site of the bite …

Incubation:

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The virus has reached the CNS …

Vector Control: Rabies, UNC-SPH 8

Incubation

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Signs of disease appear…

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Any mammal can get rabies

“Spillover”

High Risk Species

• Raccoons (land reservoir)

• Bats (reservoir)

• Red and Gray Foxes

• Striped and Spotted Skunks)

• Bobcats

• Coyotes

• Wild Carnivores

• Beavers

• Groundhogs (Woodchuck)

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Animals that CANNOT give you rabies

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How do rabid animals behave?

• May not show clinical signs. • Lethargy, vomiting, anorexia • Ataxia, weakness, paralysis, seizures • Excess salivation, difficulty swallowing,

self mutilation • May be unusually aggressive or friendly

or isolate itself.

• Abnormal behavior for the species

What is an exposure to rabies ?

Any bite, scratch or other situation in which saliva or Central Nervous System (CNS) tissue or tears* from a potentially

rabid or confirmed rabid animal enters an open wound, or comes in contact with a mucous membrane by entering the eye,

mouth or nose.

*World Health Organization Expert Consultation on Rabies. Second Report;

2013. http://apps.who.int/iris/bitstream/10665/85346/1/9789241209823_eng.pdf 48

Vector Control: Rabies, UNC-SPH 9

How is rabies transmitted?

• Bites – Highest risk, most common

• Non-bites – a risk – consult local health dept.

Saliva or Tears to open wound (scratch)

Saliva or Tears to mucous membrane

Nervous tissue to open wound (scratch)

Nervous tissue to mucous membrane

• Bats – any potential direct contact requires a careful risk assessment

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Recent Human Rabies Cases - USA

• Most recent human cases over the last 30 years have been caused by

Bats = bat variant rabies

• Cases average about 1-2 per year

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Why do Bats Pose Such a Risk?

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Seasonality of Positive Bats in NC, 2002 - 2013 (n = 347)

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What is a bat exposure?

• Thorough evaluation of all potential exposures

• If more than 1 bat, is there an infestation?

• If a single bat was it captured and tested?

• Direct contact with bat? • Was bat found in the same room with:

• a previously sleeping person, • a previously unattended child,

mentally disabled person, or intoxicated person

• Request help from Veterinary Public Health 919-733-3419

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Human Rabies – South Carolina, 2011

In situations in which bats are physically present and the person(s) cannot exclude the possibility of a bite, postexposure treatment should be considered.

Unless it was a solitary bat, and prompt testing of the bat has ruled out rabies infection.

http://www.cdc.gov/mmWr/preview/mmwrhatml/mm6232a2.htm 54

Vector Control: Rabies, UNC-SPH 10

Prevention of Rabies

• Knowledge

• Caution

• Common sense

• Personal Protection

• Pre-exposure vaccination

• Postexposure management

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• Veterinarians and staff

• Laboratory workers

• Animal control officers

• Shelter workers

• Wildlife workers

• Travelers to rabies endemic countries; at risk

http://www.cdc.gov/rabies/news/RabVaxupdate.html

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Who should receive Pre-exposure Vaccination against rabies?

Pre-exposure Immunization Regimen for People

• 3 doses of Rabies Vaccine

• Days 0, 7, and 21 or 28

• Where? Local Health Department, Physician or Travel Clinic

• RFFIT Titers – every 2 years

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Rabies Titers – Every 2 years

• Used to assess response to vaccination only! • CDC recommendation - Every 2 years • If low you will need one rabies booster • *Presence of an adequate titer does not

remove the need for PEP if indicated! • Local Health Department or Private Physician http://www.cdc.gov/rabies/resources/acip_recommendations.html

Postexposure Rabies Vaccination for People - Not Previously Vaccinated

I. Wound Cleansing; Tetanus

• +/- Antibiotics (HCP)

II. 4 Doses of Vaccine

(5 if immune compromised)

• Days 0, 3, 7, 14

• AND

III. Human Rabies

Immune Globulin (HRIG)20 IU/kg body weight, Day 0

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Postexposure Rabies Vaccination for People - Previously Vaccinated

I. Wound Cleansing

15 minutes

II. Tetanus;

• +/- Antibiotics (HCP)

II. Two Doses of Vaccine

Days 0, 3

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Vector Control: Rabies, UNC-SPH 11

Personal Protection Around Animals and their Body Fluids

• Wash your hands often after handling animals, or wear waterproof gloves, if possible

• Don’t touch your eyes, nose or mouth while handling animals

• Do not kiss animals or let them lick you • Do not eat around animals http://www.nasphv.org/Documents/ModelInfectionControlPlan.d

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CDC: Zoonotic Disease: When Humans and Animals Intersect

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Personal Protection Around Animals and their Body Fluids

• Get Rabies and Tetanus Pre-exposure prophylaxis • Wear waterproof gloves when cleaning up

after animals • Wear appropriate PPE for animals in

quarantine • Wear mask and eye goggles when

aerosolization may occur • If you are bitten, wash the wound for 15

mins under running water & soap; see a doctor (Tetanus, antibiotics, wound care)

http://www.nasphv.org/Documents/ModelInfectionControlPlan.doc

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Public Messaging Wildlife, Stray and Feral Animals

• Do not approach, feed, handle, or take in wildlife and stray animals

• If you see an animal acting strange -avoid it; report it to animal control

• Do not feed pets outside; secure garbage

• Keep pets currently vaccinated against rabies

• Supervise pets when outside

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Public Messaging Wildlife, Stray and Feral Animals

• If you are bitten…

• get to a safe place,

• report bite to animal control,

• wash the wound for 15 mins under running water & soap;

• see a doctor (Tetanus, antibiotics, wound care)

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Zoonotic Disease Information

• CDC: Healthy Pets Healthy People

http://www.cdc.gov/healthypets/index.htm

• CDC: Zoonotic Disease: When Humans and Animals Intersect

http://www.cdc.gov/247/cdcfastfacts/zoonotic.html

• CDC: Zoonotic Disease Factsheet

http://www.cdc.gov/24-7/pdf/zoonotic-disease-factsheet.pdf

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Zoonotic Disease Information

• CDC: National Center for Emerging and Zoonotic Infectious Diseases http://www.cdc.gov/ncezid/

• The Center for Food Security and Public Health http://www.cfsph.iastate.edu/Zoonoses/index.php

• The Merck Veterinary Manual http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm/bc/220100.htm

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The Center for Food Security and Public Health http://www.cfsph.iastate.edu/DiseaseInfo/fastfacts.php

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Zoonotic Disease Information • http://www.nasphv.org/Documents/VeterinaryPrecautions.pdf • http://www.nasphv.org/Documents/ModelInfectionControlPla

n.doc

• http://www.nasphv.org/Documents/ModelInfectionControlPlan.doc

• Zoonotic Disease Tutorial – Wisconsin

http://svmweb.vetmed.wisc.edu/pbs/zoonoses/

• http://www.vetinfo.com/zoonose.html • http://www.vet.cornell.edu/fhc/brochures/zoonoticdisease.ht

ml

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1902 Mail Service Center

Raleigh NC 27699-1900

Phone: (919) 733-3410

FAX: (919) 733-9555

http://epi.publichealth.nc.gov/cd/diseases/vph.html

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Veterinary Public Health

Contact Information