Rabies 2

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By: HaroldJoh (11 month(s) ago)

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By: abdul797 (11 month(s) ago)

nice presentation.

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Rabies: History, Disease in Animals and Humans, and Prevention/Control : 

Rabies: History, Disease in Animals and Humans, and Prevention/Control Howard Pue, DVM, MSVPM State Public Health Veterinarian Section for Disease Control & Environmental Epi Missouri Department of Health and Senior Services

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EXTRA, EXTRA…. ….READ ALL ABOUT IT!! “BIRD FLU PANDEMIC MAY KILL MILLIONS SOME DAY!” or “RABIES WILL KILL 40,000 WORLDWIDE THIS YEAR!” WHICH HEADLINE HAVE YOU READ RECENTLY?

Rabies: 

Rabies Viral illness of mammals, e.g. bats. Close to 100% fatal in humans; 35,000-40,000 deaths annually worldwide. Duration: 2-6 days No treatment

Background Rabies Virus: 

Background Rabies Virus Single-stranded RNA virus Non-segmented genome Prototype virus for genus Lyssavirus Neurotropic, causes fatal encephalitis Historically, dogs were the most common source Currently, most cases occur in wildlife species 2003 first report of human case due to raccoon variant Most common sources of human rabies cases in the US Bat rabies virus variants Slide courtesy CDC

Rabies Pathogenesis: 

Rabies Pathogenesis Bite Incubation - non-infectious 10 days – 6 months or possibly more Viral shedding and illness on the order of days Death Bite – virus may replicate locally. Virus goes up the nerves into the spinal cord and brain. Slide courtesy CDC

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United States Slide courtesy CDC

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Slide courtesy CDC United States

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Slide courtesy CDC United States

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What is the most common rabid domestic animal…. and less likely to be vaccinated or confined? Cats….~275 - 300 cases/year Dogs……….…~100 cases/year Slide courtesy CDC

Common Misconception Rabies is rabies is rabies….: 

Common Misconception Rabies is rabies is rabies…. There are many different rabies viruses. These are termed rabies virus variants or strains of rabies. They can be differentiated by monoclonal antibody reaction patterns (antigenic differences) and by differences in genetic sequences. Rabies virus variants are usually maintained in a single host reservoir species, although they may be transmitted to any susceptible mammal (i.e., spillover).

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Slide courtesy CDC

Signs of Rabies in Animals: 

Signs of Rabies in Animals Phase I: Prodromal (change in disposition, etc.). Phase II: Furious or “mad” rabies. Phase III: “Dumb” rabies (paralysis). Average incubation period in dogs and cats is 3 – 6 weeks.

Rabies Vaccinations and Pets: 

Rabies Vaccinations and Pets Approved by the USDA for cats, dogs, ferrets, and some large domestic animals. Only “legally” given by a licensed vet in Missouri. Rabies is rare in properly vaccinated animals.

Rabies Vaccinations for Pets: 

Rabies Vaccinations for Pets Up to local animal control ordinances. No Missouri state law requiring rabies vaccinations for pets!

Rabies Vaccinations and Wild Animals: 

Rabies Vaccinations and Wild Animals No approved vaccine; should not be vaccinated (zoos are exception). Most wild animals very susceptible. Other diseases may mimic rabies.

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Human Rabies Cases, U.S. Human Rabies Cases, United States Year

Rabies in Humans: 

Rabies in Humans In U.S. now, an average of 1 to 2 people die each year from rabies. THIS IS NOT because there is not a threat; instead – --Vaccinations for dogs/cats ($5 - $60). --Modern PH and AC practices. --More effective anti-rabies “shots” ($2,500 - $5,000)

Rabies – Children are at Particularly High Risk: 

Rabies – Children are at Particularly High Risk One study by CDC of ER visits due to dog bites: --42% of patients were kids less than 15 years old; boys higher risk than girls. --65% of injuries were to the head and neck in the 0 to 4 year old group.

Transmission is Most Often by Saliva: 

Transmission is Most Often by Saliva Bites most common by far. Minor wound may be big enough to transmit virus (bats?).

Transmission (continued): 

Transmission (continued) Nonbite exposure: --Rare! --Contamination of wounds or mucous membranes with saliva or neural tissue possible. --Should be evaluated for postexposure prophylaxis (PEP).

Transmission (continued): 

Transmission (continued) Nonbite exposures, e.g., --Large amounts of aerosolized virus (2 cases in caves, 2 cases in laboratories). --Corneal transplant recipients (8 cases, 1 in US).

Transmission (continued): 

Transmission (continued) Nonbite exposure (cont): Examples - -July 2004: --Organ transplant donor at Baylor University Medical Center died of rabies. --Four organ recipients died of rabies (Texas, Alabama, Arkansas, Oklahoma).

Transmission (continued): 

Transmission (continued) The following are usually NOT considered exposure: -Petting a rabid animal. -Contact with blood, urine, or feces (e.g., guano) of a rabid animal. -If the material containing the virus is dry (the virus is fragile; it is inactivated by desiccation and ultraviolet irradiation).

Number of Rabid Animals Detected in Missouri: 

Number of Rabid Animals Detected in Missouri Based on testing in conjunction with human or animal exposures. Does not necessarily indicate true incidence.

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Confirmed Animal Rabies Cases by Year and Species, Missouri, 1995 - 2004.

Rabies, Species, MO (2000-2004): 

Rabies, Species, MO (2000-2004) 2000 2001 2002 2003 2004 Bat 44 31 30 37 38 Skunk 5 5 13 4 19 Cat 0 1 1 1 0 Dog 0 1 0 1 1 Cow 1 0 1 0 0 Horse 0 1 0 0 0 Fox 0 1 0 0 0 Goat 0 0 0 0 1 50 40 45 43 59

Rabies Uncommon in Raccoons in Missouri: 

Rabies Uncommon in Raccoons in Missouri 1,038 raccoons tested at SPHL from 1999 through Oct 2005. -One “equivocal” in 1999 in SL County. -All others “negative.” Not very sensitive to MO strain? Raccoon strain along East Coast! PEP still indicated if not available for testing.

Low Risk Species: 

Low Risk Species There has never been a documented case of rabies transmission from a rodent or lagomorph to a human in the U.S. Case-by-case basis.

Large rodent species….: 

Large rodent species…. Consider PEP following a bite if not available for testing …. ….since they are more likely (than a small rodent) to survive an attack by a rabid animal.

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Slide courtesy CDC

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Slide courtesy CDC

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Eastern pipistrelle and Silver-haired bat Bats and The Trivial Bite Story Most human rabies cases acquired in the USA are due to rabies virus variants associated with insectivorous bats and, in particular, a specific variant associated with Eastern pipistrelle and Silver-haired bats. Insectivorous bats are small – less than 20 grams with tiny, needle-like teeth. Trauma alone, from a bat bite, is unlikely to send anyone to an emergency room. For example, an adult male dismissed a bite from a bat and decided that the risk of rabies in bats was small enough to not seek post-exposure prophylaxis. He died of rabies several weeks later. Rabies-positive red bat (Lasuirus borealis) Slide courtesy CDC

Bat Bite on Finger: 

Bat Bite on Finger Slide courtesy CDC

Human Rabies Prevention: 

Human Rabies Prevention

Signs of Rabies in People: 

Signs of Rabies in People Apprehension, headache, fever, malaise, indefinite sensory changes at site of bite (itching, numbness, tingling, etc.). Excitability, aerophobia, paralysis, spasms of swallowing muscles (hydrophobia). Delirium, convulsions, death (often due to respiratory paralysis) in 2 – 6 days. IP: Days to years (average 3 – 8 weeks).

Preexposure Vaccination (Unknown Exposure?!): 

Preexposure Vaccination (Unknown Exposure?!) Two vaccines available: --Pasteur-Merieux --Chiron Corporation Regimen the same for both: --Three 1.0 ml injections on days 0, 7, and 21 or 28.

Preexposure Vaccination, continued: 

Preexposure Vaccination, continued Given intramuscularly. Intradermal no longer available.

Preexposure Vaccination, continued: 

Preexposure Vaccination, continued CDC recommends serum titer test every two years. If titer insufficient, receive single booster dose of vaccine. Names of laboratories that test serum titer are available from DHSS. RFFIT Test !!

Preexposure Vaccination, continued: 

Preexposure Vaccination, continued Vaccine not available through Missouri Dept of Health and Senior Services. Sources of vaccine: (1) Private medical providers – regional associations may get “group rate.” (2) Travel clinics. (3) City and county health departments – may offer; check with them; will charge for vaccine plus administration.

Actions to Take When Bitten: 

Actions to Take When Bitten Identify and, if possible, confine the biting dog, cat, or ferret for quarantine (do not vaccinate) or submit head of wild animal for examination.

Actions to Take When Bitten (continued): 

Actions to Take When Bitten (continued) WOUND TREATMENT Wash immediately and thoroughly! Use soap, water, and virucidal agent (e.g., povidone-iodine solution).

Actions to Take When Bitten (continued): 

Actions to Take When Bitten (continued) SEE A DOCTOR Check tetanus status. Control bacterial infection. Suture? Depends on cosmetics and infection. Postexposure therapy?

Post-exposure Prophylaxis (PEP): 

Post-exposure Prophylaxis (PEP) A medical urgency (not an emergency) Complex decision Animal species Type of exposure Bite versus nonbite Availability of animal for rabies testing or observation

Animal Control: Quarantine or Test?: 

Animal Control: Quarantine or Test? Ten-day quarantine applies only to dogs, cats, ferrets (not to their crosses). Ten-day quarantine begins at the time of exposure.

Missouri Animal Control Association: 

Missouri Animal Control Association Professionals who help protect health of public. Conduct animal bite investigations routinely. If you don’t know them, YOU SHOULD! www.maca1.homestead.com

Considering the Need for PEP: 

Considering the Need for PEP Dogs, cats, ferrets: -If available, observe for signs of rabies for 10 days. -If remain healthy, cannot have transmitted rabies. -PEP may be needed if not available for observation. -PEP needed if animal tests positive. Wild carnivores (skunks, foxes, raccoons), bats: -High risk, test animal or PEP needed. Livestock, small rodents, rabbits: -Low risk, treat on a case-by-case basis, consult with local and state health officials.

Postexposure Therapy for Previously Vaccinated Persons: 

Postexposure Therapy for Previously Vaccinated Persons BE HAPPY! YOU ONLY NEED TWO SHOTS! 1.0 ml, IM, three days apart. No rabies immune globulin (RIG)!

Postexposure Therapy for Persons Not Previously Vaccinated: 

Postexposure Therapy for Persons Not Previously Vaccinated These people get more shots! RIG given once, IM, at the site of the bite (ouch!); 20 IU/kg. Vaccine – five doses, 1.0 ml, IM, days 0, 3, 7, 14 and 28; never in gluteal region.

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Arrange for testing of animal and human specimens at/via the State Public Health Laboratory www.dhss.mo.gov/Lab/Virology/RabiesTesting.html ANIMALS: Free shipping containers, courier service, testing. HUMANS: CDC normally wants serum, saliva, CSF, neck biopsy. SPHL web site has forms, specimen instructions, etc.

Cardinal Rules for Prevention of Rabies in the Community: 

Cardinal Rules for Prevention of Rabies in the Community 1. Ensure dogs, cats, and ferrets are UTD on vaccinations; vaccinations also available for horses, cattle, and sheep. 2. Keep pets under control; don’t run loose. 3. Avoid contact with stray pets/wild animals. 4. Do not keep wild animals or wild animal crosses as pets.

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Professional resources

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Primary Reference Documents ACIP Guidelines Human Rabies Prevention – United States, 1999, Recommendations of the Advisory Committee on Immunization Practices www.cdc.gov/mmwr/preview/mmwrhtml/00056176.htm Rabies Compendium Compendium of Animal Rabies Prevention and Control, 2005 www.cdc.gov/mmwr/preview/mmwrhtml/rr5403a1.htm DHSS Rabies Homepage www.dhss.mo.gov/Rabies

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Let’s be careful out there!!

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Dr. Howard Pue 930 Wildwood, POB 570 Jefferson City, MO 65102 Telephone: 573-751-6141 Fax: 573-526-0235 Howard.Pue@dhss.mo.gov Contact Information