1. Rabies Ancient Disease, Current Threat Ingrid Garrison, DVM, MPH, DACVPM State Public Health Veterinarian Kansas Department of Health and Environment April 10 th, 2014

2. Overview What you really need to know The Virus Epidemiology of Rabies Exposure Assessment Animal Management Human Exposure Management Rabies Postexposure Prophylaxis Case Studies

3. What You Really Need to Know Rabies risk is real in the U.S. and Kansas Exposure risk assessment crucial – Know when to give PEP – Know when not to give PEP Know animal bite reporting requirements Call your local health department or KDHE with any questions 1-877-427-7317

4. 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 4 th century B.C., Aristotle wrote ‘dogs suffer from the maddness’ 1271 A.D. – first epizootic, rabid wolves Photo – Gameofthrones.wikia.com

5. Modern Mythology

7. Global Rabies Impact One of the world’s deadliest diseases Impacts 5 billion people – 55,000 >70,000 humans deaths/year worldwide – 60% of cases in children < 15 years – 95% of deaths in Africa and Asia $124 billion annually 100% preventable

8. Rabies in the United States United States (2000-2010) – 32 human cases of rabies – 3 cases per year, median Cost of Rabies (annual) – $6 billion, total – $1.6 billion, post-exposure prophylaxis 100% preventable

9. The Virus RNA virus – Family Rhabdoviridae – Genus Lyssavirus Fusion of the rabies virus envelope to host cell membrane (adsorption) Viral budding into the salivary glad and virus-induced aggressive biting behavior in the host animal maximizes chances of viral infection of new host

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

11. Rabies in Humans Nearly always fatal once symptoms begin Tingling or itching sensation at site of the bite Flu-like illness (fever, headache) Anxiety, confusion, agitation Paralysis of muscles Death

12. Rabies in Animals Any mammal can become infected Initial signs non-specific – Restlessness – G.I. symptoms Encephalitic (furious) – Aggressive Paralytic (dumb) – Wild animals appear tame Rapid progression of signs – Death within 3-5 days of onset

13. Animal Rabies, U.S. - 2010 6,153 cases Wildlife, 92% – Raccoons (2,246) – Bats (1,430) – Skunks (1,448) Domestic animals, 8% – Cats (303) – Dogs (69) – Cattle (71)

14. Wild Animal Rabies, Kansas - 2012 Wildlife, 77% (43/56) – Skunks (34) – Bats (6) – Raccoons (2) – Coyote (1)

15. Animal Rabies, Kansas - 2012 Domestic animals, 23% (13/56) – Horses (5) – Cats (4) – Cows (4)

16. Rabies in Kansas Skunk primary reservoir – South central skunk variant Kansas State University Rabies Laboratory – Performs all diagnostic testing for Kansas Suspect and confirmed cases in animals (and humans) required to be reported to public health within 4 hours Map Courtesy CDC

17. 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 – Must be given according to label – List of licensed vaccines available in NASPHV Compendium of Animal Rabies Prevention

18. Rabies Vaccination Laws – U.S. Map courtesy of CDC, November 29, 2010

19. Rabies Vaccination Laws in Kansas No statewide law Vaccination ordinance by municipality – 637 municipalities – 350 with a municipal court Those municipalities with a court more likely to have a rabies vaccination ordinance than those that do not 10 counties with rabies vaccination laws

20. Rabies Exposure Risk Assessment

21. Rabies Lab Test Notification Phone call is required by law within 4 hours of a suspect or confirmed case KSU Rabies Lab sends results to KDHE – KDHE notifies Local Health Department of test results – If LHD unavailable, submitting vet contacted K.A.R. 28-1-13 and 28-1-14 – Authority given to the local health officer or their designee – Local health officer decision on location of quarantine

22. Local Health Department Conducts the investigation – 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.

23. Types of Exposure Bite – Any penetration of skin by teeth Non-bite – Open wound – Mucous membranes – Organ transplant

24. Types of Exposure - Bats ANY DIRECT CONTACT SHOULD BE EVALUATED FOR EXPOSURE! – Limited visible injury – Inaccurate recall of encounter Bat in same room with person – Sleeping – Unattended child – Mentally disabled person – Intoxicated person Puncture wound, palm of hand by Big Brown Bat

25. Location of Exposure Face – High risk – Rabies PEP may be started immediately

26. Circumstances of the Bite Provoked vs. unprovoked

27. Vaccination Status of the Animal Currently vaccinated Out-of-date but previously vaccinated Unknown or never vaccinated

28. Management of Biting Animal 10 day observation period – Used to determine if, at the time of the bite, the animal was shedding the rabies virus – If rabid, animal will rapidly deteriorate and die within 3-5 days of onset of signs – Location of observation determined by local health officer If dog, cat, ferret is owned – 10 day observation If dog, cat, ferret is unowned – Can euthanize and test for rabies Start PEP if animal becomes ill

29. Algorithm for Assessing Risk of Human Exposure to Rabies in Kansas Was person bitten OR was an open wound or mucous membrane exposed to the saliva or neural tissue of a mammal? Available for observation? Dog or cat Test animal for rabies. If positive, initiate PEP. If negative, no PEP needed. No PEP needed Initiate PEP as soon as possible Observe animal for 10 days Did animal show signs of rabies or die during the 10 days? Available for testing? Raccoon or skunk Small rodent Horse, cow, other livestock Bat* No PEP needed Available for testing? YES NO YES NO YESNO YES Observe animal for 30 days Consult KDHE Other mammal or special circumstances Did animal show signs of rabies or die during the 30 days? Available for observation? No PEP needed NO Initiate PEP as soon as possible YES NO

30. Management of Humans Exposed to Rabies 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

31. Rabies Immune Globluin (RIG) 20 IU/kg body weight If feasible, full dose should be infiltrated around the wound(s) and remaining volume administered around IM at site distant from vaccine administration Do not give RIG in same syringe as vaccine

32. Rabies Vaccine Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0mL, IM deltoid area – Only acceptable site of vaccination for adults and older children – Younger children, outer aspect of thigh Can administer to pregnant women Must administer vaccine within 7 days of RIG

33. Rabies Postexposure Prophylaxis (PEP) IT IS NEVER TOO LATE TO START PEP – Must give prior to onset of symptoms New recommendations by ACIP in 2009 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

34. Rabies Postexposure Prophylaxis (PEP) If unvaccinated and immunocompromised – Human rabies immunoglobluin (HRIG) – FIVE, one-mL doses of vaccine IM Day 0, 3, 7, 14, 28 Titers should be obtained 1-2 weeks after completion of series

35. Pre-exposure Vaccination Three, 1.0 ml injections – Day 0, 7, and 21 Titers checked every 2 years Booster if neutralization falls below 1:5 dilution by RFFIT If exposed to a rabid animal – Two, IM doses of vaccine (day 0, day 3)

36. No financial support from KDHE for rabies testing or rabies PEP – Usually exposed person pays for rabies testing – If unable to cover the cost it is the responsibility of the local health department to pay for testing Pharmaceutical companies have patient assistance programs that may cover the cost of PEP Rabies Postexposure Prophylaxis (PEP)

37. Rabies Serology Serology should not be used as a substitute for vaccination or to determine need for booster – Antibody titers indicate a response to vaccine or infection – Titers do not directly correlate with protection

38. Rabies Testing in Humans Call KDHE immediately! – Will coordinate testing with CDC Ante mortem (Must have all 4 samples) – Saliva – Neck Biopsy – Serum – Cerebral spinal fluid Postmortem – Fresh brain

39. Consider Human Rabies When… Signs or symptoms of encephalitis or myelitis – Autonomic instability – Dysphagia – Hydrophobia – Paresis – Paresthesia, if prodrome proceeds onset by 3-4 days Negative lab tests for common encephalitides – Herpes, enteroviruses, arboviruses

40. What You Really Need to Know Rabies risk is real in the U.S. and Kansas Exposure risk assessment crucial – Know when to give PEP – Know when not to give PEP Know animal bite reporting requirements Call your local health department or KDHE with any questions 1-877-427-7317

41. 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#r abies Centers for Disease Control and Prevention – http://www.cdc.gov/rabies/ Human Rabies Prevention (ACIP) – http://www.cdc.gov/mmwr/PDF/rr/rr5703.pdf

42. Questions?

43. 1-877-427-7317 KDHE Epidemiology Hotline Available 24/7/365 for Technical Assistance

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

45. Our Mission – To protect the health and environment of all Kansans by promoting responsible choices Sick Puppy Thursday morning a woman takes her 3.5 month old puppy to the vet for vaccinations – Physical exam normal, vaccines administered The following Monday, she returns – Puppy having difficulty standing and unable to walk During the examination, she mentions her concerns about rabies Why does she think it might be rabies? – Puppy attacked by a skunk 3 weeks prior Puppy positive for rabies

46. Our Mission – To protect the health and environment of all Kansans by promoting responsible choices Public Health Investigation LHD and vet began investigation to determine potential human exposure – Viral shedding 10 days prior to symptom onset – KDHE developed exposure questionnaire Total of 35 people potentially exposed – 21 children <14 years of age – No bites reported – Non-bite exposures, including licking the inside of the mouth and eyes

47. Our Mission – To protect the health and environment of all Kansans by promoting responsible choices Outcome Rabies postexposure prophylaxis – 4 adults (including a vet assistant) – 16 children

48. Our Mission – To protect the health and environment of all Kansans by promoting responsible choices Bats at Camp Adult camp counselors woke to bats flying around their cabin Physician at hospital told them they did not need rabies PEP KDHE contacted for consultation

49. Our Mission – To protect the health and environment of all Kansans by promoting responsible choices Public Health Investigation Determine – If other cabins had bats – If other camps utilized facilities Evaluate those at risk for rabies exposure

50. Our Mission – To protect the health and environment of all Kansans by promoting responsible choices Outcome Cabins available in April – 3 different camps overnight 2 cabins reported bats – Each cabin can hold up to 40 campers – 77 from one camp 90 total evaluated for PEP