Epidemiology of Rabies John R. Dunn, DVM, PhD Communicable and Environmental Diseases Tennessee Department of Health Centers for Disease Control and Prevention

Overview Rabies virus Rabies epidemiology in the US and Tennessee Skunk rabies Raccoon rabies and ORV Guidance documents ACIP: Pre-exposure vaccination Compendium

Rabies virus- Lyssavirus Rhabdoviridae- “bullet” shaped RNA virus Neurotropic, fatal encephalitis Variants- host adapted

Transmission Transmission: BITE of a RABID animal Virus-laden saliva contacts nerves Saliva in fresh cut or abrasion, mucous membranes (scratch?-- no) Person to person: theoretical risk, never documented in health care worker

Rabies Epidemiology in the United States

Human rabies in US: 2 – 5 cases / year Tennessee case 2002 PEP: 100% effective ~ 40,000 treatments/ year $2000 – 6,000 / treatment ~ 75% unnecessary based on rabies risk Animal rabies: 7,000 – 8,000 cases / year (wildlife) 4 variants: raccoon, skunk, bat, fox Canine variant no longer enzootic in US

Terrestrial Wildlife Rabies

Bat Rabies

Bat-associated Rabies U.S.- majority of human rabies caused by bats From 1980-2000, 26/35 (74%) cases Silver-haired/Eastern pipistrelle bat Minor wound from bat bite Difficult to detect Persons may not recognize exposure Most human rabies diagnosed post-mortem Not on differential Healthcare workers exposed

Rabies Epidemiology in Tennessee

Rabies Testing by the Tennessee Department of Health (TDH) Three testing centers Nashville Knoxville Jackson Rabies Diagnosis: Direct Fluorescent Antibody testing (DFA) of brain tissue Testing performed free of charge Not much attention paid to number and characteristics of negative results

Results from 2005 Review of laboratory slips from 3 testing centers in 2005 2017 animal submissions 2010 submitted to testing centers in TN 92 (96%) of 95 counties 362 different localities 18 out-of-state 7 additional specimens from USDA-WS surveillance program (submitted to CDC)

* *N=4: Cat 2001 (1), 2003 (1); Cow 2002 (1); Opossum 2004 (1)

TN Rabies Positives (n=48) by County, 2005 Pickett Hancock Sullivan Stewart Montgomery Robertson Sumner S - 1 Macon Clay Claiborne Johnson S - 1 Scott Hawkins Fentress Campbell B - 1 Washington R-1, S-1 Lake Trousdale Obion Weakley Henry Jackson Carter R - 2 Overton Houston Union Grainger Cheatham Smith Hamblen Greene S – 1 D - 1 Unicoi F – 1 R-1 Dickson Davidson B - 2 Wilson S - 1 Putnam B - 1 Morgan Knox B – 4 F-1 Dyer Jefferson Gibson Carroll Humphreys Dekalb Cumberland Cocke S - 2 Benton Williamson S - 4 Rutherford S – 5 H - 1 White Crockett Roane Hickman Sevier Lauderdale Cannon B - 1 Van Buren Henderson Loudon Blount Perry Warren Haywood Madison Maury B - 1 Tipton Decatur Lewis F - 1 Rhea Bedford S - 2 Coffee S-1 Bledsoe Chester Monroe B - 1 Marshall Meigs Grundy McMinn Sequatchie Moore Shelby B - 2 Fayette Hardeman Giles S - 1 Hamilton B– 2 S - 1 McNairy Hardin Wayne Lawrence Lincoln S - 2 Franklin Marion B - 1 Bradley Polk Bat - - - - - - - 16 Horse---- 1 Skunk - - - - - 23 Fox - - - - 3 Raccoon - - - -4 Dog - - - - 1

TN Rabies Positives (n=26) by County, 15 April 2006 Pickett Hancock Sullivan Stewart Montgomery Robertson Sumner Macon Clay Claiborne Johnson Scott Hawkins Fentress Campbell Washington Lake Trousdale Obion Weakley Henry Jackson Carter Overton Houston Union Grainger Cheatham Smith Hamblen Greene Unicoi C – 1 Dickson Davidson S - 2 Wilson Putnam Morgan Dyer Jefferson S-1 Gibson Carroll Humphreys Knox Dekalb Cumberland Cocke Benton Williamson S - 4 White Crockett Rutherford S – 10 Roane Hickman Sevier Lauderdale Cannon Van Buren Henderson Loudon Blount Perry Warren S-1 Haywood Madison Maury Tipton Decatur Lewis Rhea Bedford D - 1 Coffee Bledsoe Chester Monroe Marshall Meigs Grundy McMinn Sequatchie Moore S-3 Shelby Fayette Hardeman Giles Hamilton McNairy Hardin Wayne Lawrence Lincoln S - 1 Franklin Marion Bradley F-1 Polk Skunk - - 23 Fox - - 1 (Racc Var) Cat ------- 1 (Racc Var) Dog - 1 (Sk Var)

Raccoon variant

East TN counties with raccoon variant rabies, 2002-Apr 15, 2006 Pickett Hancock Sullivan Claiborne Scott Hawkins Johnson Fentress Campbell Washington Carter Overton Union Grainger Greene Hamblen Putnam Morgan Anderson Unicoi Jefferson Knox Dekalb Cumberland Cocke White Roane Sevier Van Buren Loudon Blount Warren Rhea Bledsoe Monroe Sequatchie McMinn Grundy Meigs Marion Hamilton Bradley Polk

Why is raccoon rabies problematic? Raccoons thrive in suburban settings Aggressive and swift Increase in dog and cat (2X) rabies Increase in other rabid species (foxes, groundhogs, livestock, etc.) Increase in human exposures and need for PEP risk assessment Increased animal control calls & anxiety

Tennessee response to raccoon rabies Education Reducing risk Protecting pets through vaccination Increase surveillance USDA-Wildlife Services (> 20 East TN counties) Oral rabies vaccination (ORV) campaign Appalachian Ridge baiting GAT baiting

Anticipated ORV Barrier Zone for Raccoon Rabies in the United States 2004 cases Proposed ORV

ORV in Tennessee, 2005 Appalachain Ridge GAT

Guidance documents

http://www.cdc.gov/mmwr/PDF/rr/rr4801.pdf

Imovax® (Sanofi Pasteur) Previously used off-label, 0.1ml intradermal for pre-exposure vaccination TDH no longer advocating use of Imovax off-label consistent with new ACIP recommendations Important for state, regional and local HD to promote rabies vaccination for at-risk persons

http://s94745432.onlinehome.us/RabiesCompendium.pdf

Questions? John Dunn Tennessee Department of Health Communicable and Environmental Diseases 4th Floor, Cordell Hull Building 425 5th Avenue North Nashville, TN 3724 615.741.7247