kdhe powerpoint template - johnson county, kansas · end the powerpoint with kdhe logo and website....

Our Mission: To protect and improve the health and environment of all Kansans.

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End the PowerPoint with KDHE logo and website

Rabies PreventionA Community Partnership

Ingrid Garrison, DVM, MPH, Dipl.ACVPMState Public Health Veterinarian

Kansas Department of Health and EnvironmentFebruary 21, 2018


Overview• What you really need to know• The Virus• Epidemiology of Rabies• Exposure Assessment• Animal Management• Human Exposure Management• Rabies Postexposure Prophylaxis• Animals Exposed to Rabies


Photo: US National Library of Medicine

What You Really Need to Know• Rabies risk is real in the U.S. and Kansas• Review vaccination laws for cites/county• Review animal bite reporting procedures• Know protocols for animal observation & quarantine• Protect yourself, staff, and volunteers• Call County Health Department or KDHE

with any questions1-877-427-7317


Ancient Disease• Greeks called rabies Lyssa,

or madness• Latin word ‘rabies’ from Sanskrit

‘rabhas’, means ‘to do violence’• 500 B.C., first recorded

description of canine rabies• 4th century B.C., Aristotle wrote

‘dogs suffer from the maddness’• 1271 A.D. – first epizootic, rabid

wolves


Modern Mythology

Global Rabies Impact• One of the world’s deadliest

diseases• Impacts 5 billion people• 59,000 people die from rabies

every year worldwide– 40% of cases in children – 95% of deaths in Africa and Asia

• $124 billion annually • 100% preventable

Photo: Global Alliance for Rabies Control


Human Rabies in the United States, 2008-2017


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With few exceptions, rabies occurs worldwide. The World Health Organization estimates up to 55,000 human deaths occur annually, mostly in rural areas of Africa and Asia. In the United States, between 2000 and 2006, 23 cases of human rabies were recorded, an average of 3 cases per year. The last reported human case of rabies in Kansas was in 1968. Once symptoms of rabies begin, it is considered 100% fatal. However, rabies is also 100% preventable with proper use of rabies postexposure prophylaxis.


• 23 human cases of rabies (1-3 per year)


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• 23 human cases of rabies (1-3 per year)– 8 cases, canine bite/contact outside U.S.


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• 23 human cases of rabies (1-3 per year)– 8 cases, canine bite/contact outside U.S.– 13 infected in U.S.

• 10 had contact with a bat


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• 10 had contact with a bat• Kansas

– 1968, last human case


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• 10 had contact with a bat• Kansas

– 1968, last human case• Missouri

– 2008, 55 year old male, bitten by bat, died– 2014, 52 year old male, bat exposure, died


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Impact of Human Rabies Prevention

• Half of all Americans will have been bitten by an animal at some point during their lives

• 4.5 million people bitten by dogs each year in U.S.– 316,000 treated in emergency department– 9,500 hospitalized– 10 – 20 animal bite-related deaths/year (mostly dogs)– $50,000,000 in inpatient costs/year

• Most dog bite victims are children• 30,000 – 60,000 courses of rabies post-exposure

prophylaxis are administered annually in the U.S.– Cost of Rabies = $245-510 million/year


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https://www.aafp.org/afp/2014/0815/p239.html https://www.cdc.gov/rabies/location/usa/cost.html

Impact of Animal Rabies Prevention in Kansas - 2015

• 1,182 animals tested for rabies– Domestic animals usually tested b/c of bite to human

• 100 rabies positive animals– Plus an additional 14 unsuitable specimens (treated like a positive)

• 46 rabid animals had at least 1 animal contact– A total of 91 animal contacts identified; 43 euthanized,

16 quarantined for 6 months• 43 rabid animals had at least 1 human contact

– 89 human contacts identified• 48 recommended PEP; 76 received PEP


What is Rabies?


Rabies Virus• Bullet-shaped virus• Any mammal can be infected

– Animals that have fur, bear live young, produce milk

• Virus only found in saliva and neural tissue

• Does not survive long in the environment – Inactivated by drying, sunlight,

disinfectant


1) Virus in saliva. 2-4) Incubation period variable, depends on location of bite. Victim asymptomatic. PEP will prevent disease. 5) Encephalitis, symptomatic. 6) Victim infectious. Virus shed 10 days prior to symptom onset.


Rabies in Humans• Nearly always fatal once

symptoms begin• Tingling or itching sensation

at site of the bite• Non-specific illness prior to

neurologic symptoms– Flu-like illness (fever, headache)

• Rapid progression (days) to neurologic signs– Anxiety, confusion, agitation– Paralysis of muscles

• DeathOur Mission: To protect and improve the health and environment of all Kansans.

Rabies in Animals• Any mammal can become infected

– 3 – 12 week incubation period (highly variable)• Initial signs non-specific

– Restlessness, G.I. signs, lameness• Encephalitic (furious)

– Aggressive• Paralytic (dumb)

– Wild animals appear tame• Rapid progression of signs

– Cannot swallow (foaming at mouth)– Cannot breathe– Death within 3-5 days of onset


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The course of disease is similar in humans and animals. The initial symptoms of rabies are often non-specific and may include restlessness and gastrointestinal symptoms, such as diarrhea, vomiting, and anorexia. There are two forms of rabies; encephalitic (furious) and paralytic (dumb). During encephalitic rabies, animals may become very aggressive and may roam, biting humans and other animals. In paralytic rabies, paralysis is the predominant manifestation of disease. This often begins with paralysis of the jaw accompanied by excessive salivation because of an inability to swallow. Owners may think that the animal has a foreign body stuck in its throat and expose themselves while attempting to remove the “foreign” object.

8 Month Old Cat with Rabies

Video from Bayside Animal Hospital


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https://www.youtube.com/watch?v=H8fbAFOMTp4

Cow with Rabies


Video from Dr. Duane DrogeDroge Animal Health Center

Eureka, Kansas

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https://www.youtube.com/watch?v=01gXa8KkuPA

Terrestrial Rabies Reservoirs – U.S., 2015

Distribution of major rabies virus variants among mesocarnivores in the U.S. and Puerto Rico, 2008-2014. Black diagonal lines represent fox rabies variants (Arizona gray fox and Texas gray fox). Solid borders represent 5-year rabies virus variant aggregates for 2010 through 2015; dashed borders represent the previous 5-year aggregates for 2009 through 2014. Map courtesy CDC.


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Many wild and domestic animals are reservoirs for rabies. In developing countries, dogs are the principal reservoir. However, wild animals are the most important source of infection for both humans and animals in the United States. The specific wild animal reservoir for rabies is dependent mainly on geography. Raccoons are the sole terrestrial reservoir for the entire eastern U.S. Rabid skunks are widespread in the U.S. and can be found in four main geographic regions; the eastern U.S., north central U.S., south central U.S., and California. Fox rabies is present in Texas, New Mexico, Arizona, California, and Alaska⁹. Due to their greater mobility, rabies virus variants associated with bats are broadly distributed across geographic ranges in the U.S. The recognized spatial boundaries of these rabies virus variants change over time as a result of many natural (eg, droughts) and anthropogenic (eg, housing development) factors affecting the corresponding reservoir species.3 http://avmajournals.avma.org/doi/full/10.2460/javma.243.6.805


Animal Rabies, U.S. – 2015N = 5,508 total

92% Wildlife



92% Wildlife

1,704 (30.9%), bats


Reported cases of rabies involving bats, by county, during 2015.

Histogram represents number of counties in each category for total number of bats submitted for rabies testing. Point locations for rabid bats were randomly selected within each reporting jurisdiction. Map courtesy CDC.

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https://avmajournals.avma.org/doi/full/10.2460/javma.250.10.1117



92% Wildlife

1,704 (30.9%), bats 1,619 (29.4%), raccoons

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Reported cases of rabies involving raccoons, by county, during 2015.

Histogram represents number of counties in each category for total number of raccoons submitted for rabies testing. Point locations for rabid raccoons were randomly selected within each reporting jurisdiction. Map courtesy CDC.

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92% Wildlife

1,704 (30.9%), bats 1,619 (29.4%), raccoons 1,365 (24.8%), skunks

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Reported cases of rabies involving skunks, by county, during 2015.

Histogram represents number of counties in each category for total number of skunks submitted for rabies testing. Point locations for rabid skunks were randomly selected within each reporting jurisdiction. Map courtesy CDC.

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8% Domestic Animals



8% Domestic Animals

244 (4.4%), cats


Reported cases of rabies involving cats, by county, during 2015.

Histogram represents number of counties in each category for total number of cats submitted for rabies testing. Point locations for rabid cats were randomly selected within each reporting jurisdiction. Map courtesy CDC.

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8% Domestic Animals

244 (4.4%), cats 85 (1.5%), cattle



8% Domestic Animals

244 (4.4%), cats 85 (1.5%), cattle 67 (1.2%), dogs


Reported cases of rabies involving dogs, by county, during 2015.

Histogram represents number of counties in each category for total number of dogs submitted for rabies testing. Point locations for rabid dogs were randomly selected within each reporting jurisdiction. Map courtesy CDC.

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Animal Rabies, Kansas – 2015N = 100 total

76% Wildlife



76% Wildlife

67 (67%), skunks



76% Wildlife

67 (67%), skunks 6 (6%), bats



76% Wildlife

67 (67%), skunks 6 (6%), bats 3 (3%), foxes



24% Domestic Animals




12 (12%), cows




12 (12%), cows 11 (11%), cats




12 (12%), cows 11 (11%), cats 1 (1%), horses


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https://keap.kdhe.state.ks.us/Ephtm/PortalPages/ContentData

Rabies Positive Animals in KS, NE – 2015


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www.vet.ksu.edu/rabies

Rabies Positive Animals in KS – 2015


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https://keap.kdhe.state.ks.us/Ephtm/EphtContent/documents/Reports/Rabies_Annual/atlas.html?indator=i0&date=2016&indicator2=i2&date2=2016

Rabies Positive Animals in MO – 2015


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http://health.mo.gov/living/healthcondiseases/communicable/rabies/reports.php


Slide Courtesy Dr. James Kazmierczak

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Local governments should initiate and maintain effective programs to ensure vaccination of all dogs, cats, and ferrets and to remove stray and unwanted animals. Such procedures have reduced laboratory- confirmed cases of rabies among dogs in the United States from 6,949 cases in 1947 to 89 cases in 2013. Because more rabies cases are reported annually involving cats (247 in 2013) than dogs, vaccination of cats should be required. (From NASPHV Rabies Compendium, 2016)

Animal Vaccination• Vaccination of domestic animals provide a buffer

between wildlife and people• Licensed rabies vaccine

– Dogs, cats, ferrets, horses, cattle, sheep

– Must be given by veterinarian or under direct supervision of vet (KS)

– Should be given according to label


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Photo Credit: http://animalpetdoctor.homestead.com/arab2.jpg

Rabies Vaccination Laws, Kansas

• No statewide law• Vaccination ordinance

by municipality– 637 municipalities

• 10 counties with rabies vaccination law

• Johnson County– 20 municipalities


Compendium of Animal Rabies Prevention and Control

• Published by National Assoc. of State Public Health Vets• Recommendations serve as a basis for animal rabies

prevention and control programs throughout the U.S.– Updated ~5 years (2016 most current)– Does not supersede state and local laws/requirements– Many State Health Departments base animal rabies prevention

and control regulations on these recommendations • Includes information on;

– Principles of rabies prevention and control– Recommendations for parenteral vaccination procedures– All animal rabies vaccines licensed by USDA

Rabies Vaccination Highlights from Compendium

• All animal rabies vaccines should be restricted to use by or under the direct supervision of a veterinarian on premises

• Document, document, document! • Regardless of the age of the animal at initial vaccination a

booster should be administered 1 year later– Give subsequent booster vaccinations according to label

• No lab or epi data to support the annual or biennial administration of 3-year vaccines after completion of the initial series

Animal Rabies Vaccination• Vaccinate all dogs, cats,

ferrets, and horses• Vaccinate valuable

livestock and animals that have frequent human contact (e.g. petting zoo)– If it has a name, vaccinate!

• In Kansas, it is illegal to own, and vaccinate, pet skunks, foxes, raccoons, coyotes

Photo Courtesy Dr. Ingrid Garrison

What About Rabies Titers in Animals?

• Rabies virus antibody titers are indicative of a response to vaccine or infection

• Titers do not directly correlate with protection because other immunologic factors also play a role in preventing rabies– Our abilities to measure and interpret those other factors are not

well-developed (NASPHV Rabies Compendium, 2016)• Therefore, evidence of circulating rabies virus antibodies

in animals should not be used as a substitute for current vaccination in managing rabies exposures or determining the need for booster vaccination

So How Can I Avoid Liability in My Vaccine Protocol?

• AVMA Medical Law Association White Paper (2009)– Vaccine Liability Issues for Veterinarians

• Stay abreast of developments in the veterinary profession – Scientific, peer-reviewed articles supporting appropriate

vaccination protocols – Follow decisions in your jurisdiction by the courts & state vet board

• Practice the duty to inform– Verbal discussion with client– Provide written material that outlines reasons for vaccination

• Disclose risk, duration of immunity, practice position statement on vax policy

• Obtain owner’s consent prior to vaccination• Properly document!!!

Rabies is Reportable!• Phone call is required by law within 4 hours of a suspect or

confirmed case– Health-care providers

• Kansas State University Rabies Laboratory sends results to KDHE– KDHE notifies local health department (LHD)

of test results– If LHD unavailable, submitting vet contacted

• K.A.R. 28-1-13, Rabies Control – Authority given to the local health officer or

their designee


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LHO or designee has decision on location of observation or quarantine. They also make the call whether animal is suffering from rabies and authorize the release of animals from observation or quarantine.

Rabies Exposure Risk Assessment

• Information needed when evaluating people who came into contact with a known rabid animal

Or• Information needed when evaluating

people with animal bites


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Assessing human exposures must be done on a case-by-case basis. A good history should always be taken; information on the species of the animal involved in the exposure, the type of exposure (e.g. the site of a bite, scratch or abrasion), the age of the victim, and the previous rabies and tetanus vaccination history of the victim should always be obtained. Information on the vaccination status of the animal and whether the exposure was provoked or unprovoked may be helpful but is not crucial in evaluating human exposure.

Public Health Investigation


Human Rabies Prevention – U.S.

• Advisory Committee on Immunization Practices (ACIP)– Provides updated information on human/animal

rabies epidemiology– Summarizes effectiveness/efficacy and safety of

rabies biologics– Recommendations for rabies postexposure and

pre-exposure prophylaxis– Treatment considerations for human rabies patients


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https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/rabies.html

Local Health Department• Conducts the investigation (known rabid animal)

– Collects information about the incident– Conducts exposure assessment– Makes PEP recommendations

• Evaluate all people/animals that came into contact with the rabid animal 10 DAYS PRIOR TO ONSET OF CLINICAL SIGNS– This includes veterinarians, veterinary staff,

animal control officers, etc.


Rabies Exposure Risk Assessment• Species of animal causing

exposure• Type of exposure

– Bite vs. non-bite• Location of bite• Vaccination status of animal• Normal vs. abnormal behavior

– Provoked vs. unprovoked


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Assessing exposures must be done on a case-by-case basis. A good history should always be taken; information on the species of the animal involved in the exposure, the type of exposure (e.g. the site of a bite, scratch or abrasion), the age of the victim, the previous rabies and tetanus vaccination history of the victim should always be obtained, information on the vaccination status of the animal, and whether the exposure was provoked or unprovoked.

Types of Exposure• Bite

– Any penetration of skin by teeth

• Non-bite– Open wound– Mucous membranes– Organ transplant– Scratch?


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Rabies virus is found in the saliva and neural tissues of infected animals. A bite exposure is any penetration of the skin by teeth. Although this is the most common rabies exposure, there are other routes of infection. The contamination of open wounds or abrasions (including scratches) or mucous membranes with saliva or other potentially infectious material (e.g., neural tissue) from a rabid animal also constitutes a nonbite exposure. Rabies virus is inactivated by desiccation, ultraviolet irradiation, and other factors and does not persist in the environment. In general, if the suspect material is dry, the virus can be considered noninfectious. Nonbite exposures other than organ or tissue transplants have almost never been proven to cause rabies, and postexposure prophylaxis is not indicated unless the nonbite exposure met the definition of saliva or other potentially infectious material being introduced into fresh, open cuts in skin or onto mucous membranes. Photo: http://www.kent.police.uk/Training%20and%20facilities/Courses/Dog%20training/Puppy%20bite%20-%20web.jpg

Bats and Rabies

Photo Credit: The Lancet, 2001, Vol. 357, pp 1714

• Any direct contact should be evaluated for exposure due to;• Limited visible injury• Inaccurate recall of encounter

• Test bat, or PEP recommended, if bat in same room with person;• Sleeping• Unattended child• Mentally disabled person• Intoxicated person


More to Add About Bats• Reports of bats in or around

homes increase in July and August– Baby bats learn to fly

• If a person reports a bat in their home the structure should be inspected to insure no additional bats

• Bats should be excluded, not exterminated– Bat ‘vent’ allows bats to

escape but not returnOur Mission: To protect and improve the health and environment of all Kansans.

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Photo from: http://www.batsintheattic.org/exclusion.html

Which Animals Pose a Risk to Humans?

• Bat• Cat• Coyote• Dog• Ferret• Fox• Horse• Large rodents (muskrat, beaver)• Livestock• Other carnivores • Raccoon• Skunk

• Rabbits/hares• Chipmunks• Squirrels• Pet rats, hamsters,

gerbils• Other small rodents• Opossum

Higher / More Likely Lower / Less Likely


No PEP recommended unless animal

behaving abnormally / neurologic

Location of Exposure• Face

– High risk (short distance for virus to travel to the brain)

– Rabies PEP may be started immediately


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Recent deaths in the U.S. from bat-associated rabies strains in which the deceased had no identifiable exposure to a bat has prompted the recommendation that exposures to bats in which a bite or non-bite exposure is a reasonable probability warrants rabies post-exposure prophylaxis if the bat is unavailable for testing. Persons waking to find a bat in their bedroom, an adult finding a bat in the bedroom of an unattended young child, or an adult finding a bat in the same room as a person under the influence of alcohol or other drugs are examples of situations where exposure cannot reasonably be excluded and post-exposure treatment should be started if the bat is unavailable for testing. Bites occurring on the face are considered high risk and rabies post-exposure prophylaxis is often started immediately. If an owned dog, cat, or ferret is available for observation or the animal is available for testing, post-exposure prophylaxis may be started then stopped if the animal is shown not to be rabid. Figures 1 and 2 describe current recommendations for evaluating human exposures to rabies.

Normal or Abnormal Behavior?• Does the dog have a

history of biting or other aggressive behavior?

• If yes, less likely to be rabies

• Is the dog currently vaccinated?

• If yes, less likely to be rabies

• Was the bite ‘provoked’ ?• If yes, less likely to be

rabies

Vaccination Status of the Animal• Currently vaccinated

– Low risk of rabies• Out-of-date but

previously vaccinated– Low risk of rabies

• Unknown or never vaccinated– Higher risk of rabies


10 Day Observation Period


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A healthy domestic dog, cat, or ferret that bites a person should be confined and observed for 10 days. Those that remain alive and healthy 10 days after a bite would not have been shedding rabies virus in their saliva and would not have been infectious at the time of the bite. All domestic dogs, cats, and ferrets kept as pets should be vaccinated against rabies. Even if they are not, such animals might still be confined and observed for 10 days after a bite to reliably determine the risk for rabies exposure for the person who was bitten. Any illness in the animal during the confinement period before release should be evaluated by a veterinarian and reported immediately to the local public health department. If signs suggestive of rabies develop, postexposure prophylaxis of the bite victim should be initiated. The animal should be euthanized and its head removed and shipped, under refrigeration, for examination by a qualified laboratory. If the biting animal is stray or unwanted, it should either be confined and observed for 10 days or euthanized immediately and submitted for rabies diagnosis.



• Used when DOG/CAT bites HUMAN

• Can wait to administer PEP

• Do not vaccinate the dog/cat during observation

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• Location of observation determined by local health officer (K.A.R. 28-1-13)

• Home, vet, shelter• If animal develops

signs of rabies, euthanize and test

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When Dog/Cat Bites a Human = 10 Day Observation Period


• Location of observation determined by local health officer (K.A.R. 28-1-13)

• Home, vet, shelter• If animal develops

signs of rabies, euthanize and test

• If alive at day 10 it does not have rabies

• If not current, vaccinate dog/cat at end of observation




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Vora, et. all. Animal Bite and Rabies Postexposure Prophylaxis Reporting – U.S, 2013. J Public Health Management Practice, 2015, 21 (3), E24-E27.

Management of Humans Who Are Bitten or Exposed

• Bite wounds– Immediately wash with soap and water– Tetanus booster recommended– Appropriate antibiotic therapy

• Non-bite exposures– Immediately flush mucous membranes with

clean water• Can wait to administer PEP

– If animal is available for observation– If animal is being tested for rabies



Centers for Disease Control and Prevention. Human Rabies Prevention – U.S., 2008. Recommendations of the Advisory Committee on Immunization Practices. MMWR 2008;57(No.RR-3): pg 11.

Rabies PostexposureProphylaxis (PEP)

• IT IS NEVER TOO LATE TO START PEP– Must give prior to onset of symptoms

• Medical urgency, not an emergency• If previously unvaccinated and healthy

– Human rabies immunoglobluin (HRIG), 20 IU/kg– FOUR, one-mL doses of vaccine IM (never in gluteal

area)• Day 0, 3, 7, 14


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HRIG is administered only once (i.e., at the beginning of antirabies prophylaxis) to previously unvaccinated persons to provide immediate, passive, rabies virus-neutralizing antibody coverage until the patient responds to HDCV or PCECV by actively producing antibodies. If HRIG was not administered when vaccination was begun (i.e., day 0), it can be administered up to and including day 7 of the postexposure prophylaxis series Two rabies vaccines are available for use in the United States (Table 1); either can be administered in conjunction with HRIG at the beginning of postexposure prophylaxis. A regimen of 4 one-mL doses of HDCV or PCECV should be administered IM to previously unvaccinated persons who are healthy. The first dose of the 4-dose course should be administered as soon as possible after exposure. This date is then considered day 0 of the postexposure prophylaxis series. Additional doses should then be administered on days 3, 7, and 14 after the first vaccination. For adults, the vaccination should always be administered IM in the deltoid area. For children, the anterolateral aspect of the thigh is also acceptable. The gluteal area should never be used for HDCV or PCECV injections because administration of HDCV in this area results in lower neutralizing antibody titers (156). For those individuals who are immunocompromised HRIG plus 5 doses of vaccine (day 0, 3, 7, 14, and 28) are needed.

Protect Yourself and Your Staff• Pre-exposure vaccination recommended for

people with high risk of exposure (e.g. Vets, Animal Control Officers)– Only allow vaccinated staff to handle rabies

observation, quarantine, or suspect animals• Three, 1.0 ml injections

– Day 0, 7, and 21• Titers checked every 2 years

– Booster if titer falls below 1:5 dilution by RFFIT• If exposed to a rabid animal

– Two, IM doses of vaccine (day 0, day 3)– No HRIG


MANAGEMENT OF ANIMALS EXPOSED TO RABIES


Important Notes on Animal Quarantine

• Kansas Administrative Regulation 28-1-13 gives authority to Local Health Officer, or Secretary of KDHE, to determine the location of the animal quarantine

• Public Health Officials rely on veterinarians to provide information to help determine animal exposure– However final decision on

exposure status of the animal is determined by the Local Health Officer


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Photo Credit: https://mypaintbynumbers.com/products/puppies-corner-a-skunk

Compendium of Animal Rabies Prevention and Control

• Maintained by the National Association of State Public Health Veterinarians (NASPHV)

• First document published in 1971 by CDC, NASPHV took over in 1975

• Last updated in 2011

• Significant changes made to recommendations of animals exposed to rabies (March 2016) due to results of KSU study in addition to Texas study


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In the early 1970s, major changes were occurring in the manufacture of rabies vaccines as companies changed from nervous tissue and chick embryo vaccine to tissue culture. This inspired Dr. Keith Sikes at CDC to publish in 1971 the first "Compendium of Animal Rabies Vaccines". CDC continued to publish the compendium in 1973 and 1974, but conflicts between United State Department of Agriculture (USDA) and CDC bottlenecked further publication. NASPHV accepted the responsibility and since 1975, there has been a Compendium Committee which has met to update the Compendium every year. With the assistance of the United States Department of Agriculture, CDC, the American Veterinary Medical Association (AVMA), the Conference of State and Territorial Epidemiologists, and the commercial rabies vaccine manufacturers, the Compendium Committee has developed national rabies control recommendations standardizing vaccination procedures and rabies control practices for animals. Texas paper: https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0ahUKEwij_MeL45PLAhVJ-GMKHZS0AuQQFggxMAM&url=https%3A%2F%2Fwww.avma.org%2FNews%2FJournals%2FCollections%2FDocuments%2Fjavma_237_12_1395.pdf&usg=AFQjCNHwn2me4MbuNn165T9zh__FHb_uNQ&cad=rja Objective—To determine whether postexposure rabies prophylaxis (PEP) in domestic animals, as mandated in Texas, has continued to be effective and to evaluate preexposure or postexposure vaccination failures from 2000 through 2009. Design—Retrospective case series. Animals—1,014 unvaccinated domestic animals (769 dogs, 126 cats, 72 horses, 39 cattle, 3 sheep, 4 goats, and 1 llama) that received PEP and 12 vaccinated domestic animals (7 dogs and 5 cats) with possible failure of protection. Procedures—Zoonotic incident reports from 2000 through 2009 were reviewed for information regarding unvaccinated domestic animals that received PEP in accordance with the state protocol after exposure to a laboratory-confirmed rabid animal; reports also were reviewed for any preexposure or postexposure vaccination failures. The state-required PEP protocol was as follows: immediately vaccinate the animal against rabies, isolate the animal for 90 days, and administer booster vaccinations during the third and eighth weeks of the isolation period. Results—From 2000 through 2009, 1,014 animals received PEP; no failures were recorded. One preexposure vaccination failure was recorded. Conclusions and Clinical Relevance—The Texas PEP protocol was used during the 10- year period. Results indicated that an effective PEP protocol for unvaccinated domestic animals exposed to rabies was immediate vaccination against rabies, a strict isolation period of 90 days, and administration of booster vaccinations during the third and eighth weeks of the isolation period. (J Am Vet Med Assoc 2010;237:1395–1401)

Current Scientific EvidenceKSU Rabies Laboratory• Study compared antibody response of dogs and cats with a

current vaccination to those that were out-of-date after being exposed to rabies

• Results indicated dogs and cats with an out-of-date rabies vaccination have similar antibody response to rabies booster when compared to dogs and cats with current vaccine

• http://avmajournals.avma.org/doi/pdf/10.2460/javma.246.2.205


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In 2015, researchers at the Kansas State University Rabies Laboratory published data on a study in which they compared the antibody response of dogs and cats that were exposed to rabies and overdue for their rabies vaccination to dogs and cats that were current on vaccination. The results indicated that dogs and cats with an out-of-date rabies vaccination have a similar response to a rabies booster when compared to those with a current vaccination. Dogs were not inferior in their antibody response following booster rabies vaccination, compared to dogs with current vaccination status.

No Animals with an Out-of-Date Vaccine Developed Rabies

• Evaluated outcome of animals exposed to reported rabies cases (Kansas, 2012 – 2015)

• 114 rabid animals with at least 1 animal contact– 219 animal contacts

• 31% (68/219) currently vaccinated• 15% (32/219) out-of-date• 49% (108/219) unvaccinated• 5% (11/219) unknown

• 32 out-of-date contacts– 50% (16/32) were euthanized– 50% (16/32) were quarantined; 14 survived,

1 tested negative for rabies, 1 lost-to-follow-upOur Mission: To protect and improve the health and environment of all Kansans.

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There were 114 rabid animal cases with at least one animal contact. Two-hundred nineteen animal contacts were potentially exposed to rabies; 68 (31%) were current on rabies vaccination, 32 (15%) were out-of-date, 108 (49%) were unvaccinated, and 11 (5%) had unknown vaccination status. Of the 32 out-of-date contacts, 16 (50%) were euthanized and 16 (50%) were quarantined (14 survived, 1 exhibited neurological signs and tested negative for rabies, and 1 was lost to follow-up). For the 108 unvaccinated contacts, 81 (75%) were euthanized, 1 (1%) developed neurological signs and tested positive for rabies, and 26 (24%) were quarantined (23 survived, 2 died from unrelated causes, and 1 was lost to follow-up). For the 11 animal contacts with unknown vaccination, 9 (82%) were euthanized and 2 (18%) were quarantined (1 exhibited neurological signs and tested negative for rabies and 1 was lost to follow-up). CONCLUSIONS: No animal contacts with out-of-date rabies vaccination developed rabies during a six-month quarantine after exposure to a known rabid animal. One unvaccinated animal contact developed rabies; however, a majority of unvaccinated animals were euthanized immediately. Policy changes could be considered to manage out-of-date dog and cat contacts similarly to those that are current on rabies vaccination. This would reduce the number of animals euthanized and burden on scarce public health resources.

No Animals with an Out-of-Date Vaccine Developed Rabies

• Evaluated outcome of animals exposed to reported rabies cases (Kansas, 2012 – 2015)

• 114 rabid animals with at least 1 animal contact– 219 animal contacts

• 31% (68/219) currently vaccinated• 15% (32/219) out-of-date

• 49% (108/219) unvaccinated• 5% (11/219) unknown

• 32 out-of-date contacts– 50% (16/32) were euthanized– 50% (16/32) were quarantined; 14 survived,

1 tested negative for rabies, 1 lost-to-follow-up


Presenter

Presentation Notes

There were 114 rabid animal cases with at least one animal contact. Two-hundred nineteen animal contacts were potentially exposed to rabies; 68 (31%) were current on rabies vaccination, 32 (15%) were out-of-date, 108 (49%) were unvaccinated, and 11 (5%) had unknown vaccination status. Of the 32 out-of-date contacts, 16 (50%) were euthanized and 16 (50%) were quarantined (14 survived, 1 exhibited neurological signs and tested negative for rabies, and 1 was lost to follow-up). For the 108 unvaccinated contacts, 81 (75%) were euthanized, 1 (1%) developed neurological signs and tested positive for rabies, and 26 (24%) were quarantined (23 survived, 2 died from unrelated causes, and 1 was lost to follow-up). For the 11 animal contacts with unknown vaccination, 9 (82%) were euthanized and 2 (18%) were quarantined (1 exhibited neurological signs and tested negative for rabies and 1 was lost to follow-up). CONCLUSIONS: No animal contacts with out-of-date rabies vaccination developed rabies during a six-month quarantine after exposure to a known rabid animal. One unvaccinated animal contact developed rabies; however, a majority of unvaccinated animals were euthanized immediately. Policy changes could be considered to manage out-of-date dog and cat contacts similarly to those that are current on rabies vaccination. This would reduce the number of animals euthanized and burden on scarce public health resources.

Rabies Memorandum – March 1, 2016


When an Animal is Bitten by a Rabid Animal

• If a dog, cat, ferret, horse, cow, or sheep is currently vaccinatedagainst rabies– Immediately booster and observe

for 45 days


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Presentation Notes

The rationale for an observation period is based in part on the potential for: overwhelming viral challenge, incomplete vaccine efficacy, improper vaccine administration, variable host immunocompetence

When a Dog or Cat is Overdue

• Dog or cat has been exposed to rabies, is overdue for vaccination, but has documentation of at least one rabies vaccine in its life– Immediately booster and OBSERVE for 45 days– If booster is delayed, observation period may be

increased


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Presentation Notes

Dogs and cats that are overdue for a booster vaccination and that have appropriate documentation of having received a USDA-licensed rabies vaccine approved for that species at least once previously should immediately receive veterinary medical care for assessment, wound cleansing, and booster vaccination. The animal should be kept under the owner’s control and observed for 45 days. If booster vaccination is delayed, public health officials may consider increasing the observation period for the animal, taking into consideration factors such as the severity of exposure, the length of delay in booster vaccination, current health status, and local rabies epidemiology.

When a Dog or Cat is Overdue with No Documentation

• Prospective serologic monitoring – must consult with KDHE– Collect 1-2 cc of serum and refrigerate– Administer booster vaccination (within 96 hours following exposure)– Collect 1-2 cc of serum 5 days (up to 7 days) after first serum

collection and refrigerate– Ship paired serum together to KSU– Animal must be in quarantine until results are available

• Adequate response – OBSERVE for 45 days• Inadequate response – QUARANTINE for 4 months

OR

• Treat as unvaccinated


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Presentation Notes

Dogs and cats that are overdue for a booster vaccination – but without appropriate documentation of having received a USDA-licensed rabies vaccine approved for that species at least once previously – should immediately receive veterinary medical care for assessment, wound cleansing, and consultation with KDHE or local public health authorities. Two options are recommended for managing these animals: a. Prior to booster vaccination, the attending veterinarian may request guidance from KDHE or the local public health authorities in the possible use of prospective serologic monitoring. Such monitoring would entail collecting paired blood samples to document prior vaccination by providing evidence of an anamnestic response to booster vaccination. Collect 1-2cc of serum from exposed animal. This should be kept refrigerated and held until the second serum is collected. ASAP after the exposure and refrigerate it. If an adequate anamnestic response is documented, the animal can be considered to be overdue for booster vaccination and observed for 45 days. If there is inadequate evidence of an anamnestic response, the animal is considered to have never been vaccinated and should be placed in strict quarantine for 4 to 6 months. b. The animal can be treated as unvaccinated, immediately given a booster vaccination and placed in strict quarantine for 4 to 6 months.

Unvaccinated Dogs and Cats

• EuthanizeOR• 4-month QUARANTINE

– Vaccinate at time of entry into quarantine– K-State Protocol recommended for naïve animals

• Give 3 vaccines; one on day 0, 7, and 21-28


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Presentation Notes

Dogs, cats, and ferrets that have never been vaccinated against rabies should be euthanized immediately. There are currently no United States Department of Agriculture (USDA)-licensed biologics for postexposure prophylaxis of previously unvaccinated domestic animals, and there is evidence that the use of vaccine alone will not reliably prevent the disease in these animals. If the owner is unwilling to have the animal euthanized, the animal should be placed in strict quarantine for 4 months (for dogs and cats) or 6 months (for ferrets). Strict quarantine in this context refers to confinement in an enclosure that precludes direct contact with people and other animals. A rabies vaccine should be administered at the time of entry into quarantine to bring the animal up to current rabies vaccination status. Administration of vaccine should be done as soon as possible. It is recommended that the period from exposure to vaccination not exceed 96 hours. If vaccination is delayed, public health officials may consider increasing the quarantine period for dogs and cats from 4 to 6 months, taking into consideration factors such as the severity of exposure, the length of delay in vaccination, current health status, and local rabies epidemiology.

What You Really Need to Know• Rabies risk is real in the U.S. and Kansas• Review vaccination laws for cites/county• Review animal bite reporting procedures• Know protocols for animal observation & quarantine• Protect yourself, staff, and volunteers• Call County Health Department or KDHE

with any questions1-877-427-7317


Our Mission – To protect the health and environment of all Kansans by promoting responsible choices

Resources• KDHE Epi Hotline – 1-877-427-7317

– http://www.kdheks.gov/epi/human_animal_health.htm#rabies

• Kansas Rabies Data (2012 – Present)– https://keap.kdhe.state.ks.us/Ephtm/PortalPages/Cont

entData• K-State Rabies Laboratory

– http://www.ksvdl.org/rabies-laboratory/• Missouri Rabies Reports (2007 – Present

– http://health.mo.gov/living/healthcondiseases/communicable/rabies/reports.php


http://www.kdheks.gov/epi/human_animal_health.htm#rabies

https://keap.kdhe.state.ks.us/Ephtm/PortalPages/ContentData

http://www.ksvdl.org/rabies-laboratory/

http://health.mo.gov/living/healthcondiseases/communicable/rabies/reports.php

Our Mission – To protect the health and environment of all Kansans by promoting responsible choices

Resources• Centers for Disease Control and Prevention

– http://www.cdc.gov/rabies/• Animal Rabies Compendium

– http://www.nasphv.org/documentsCompendia.html• Human Rabies Vaccine Recommendations

– https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/rabies.html


http://www.cdc.gov/rabies/

http://www.nasphv.org/documentsCompendia.html

https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/rabies.html

Questions?



www.kdheks.govIngrid C. Garrison, DVM, MPH, Dipl. ACVPM

State Public Health VeterinarianBureau of Epidemiology and Public Health Informatics

Kansas Department of Health and Environment

785-296-2501 [email protected]

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Presentation Notes

End the PowerPoint with KDHE logo and website