1. Rabies Investigations: Are we chasing our tail? Robyn M Atkinson, PhD Tennessee Department of Health EPHLI Cohort IV

2. Rabies Genus – Lyssavirus – “rage” Family – Rhabdoviridae – “Bullet Shaped” Single stranded, negative sense, RNA virus Travels along neurons to the brain

3. Rabies Canine variant rabies eliminated in 1940’s and 1950’s Dogs may be infected with other strain variants – 94 reported in 2004 Raccoons, skunks, and bats —account for >85% of all reported cases of animal rabies since 1976 Total of 21 human cases between 2000 – 2004 –15 were due to bat exposures No geographic boundaries for bats! – Makes rabies endemic in contiguous US Every year approximately 16,000–39,000 persons receive post-exposure prophylaxis

4. Rabies Disease in Animals Incubation period- unknown – can be up to 6 months or longer Symptoms similar to those of humans: –Hydrophobia, aerophobia, hypersalization, confusion, aggression No good experimental model to study natural infection

5. Ironically, we DO NOT accept human specimens! Test only animal brains The animal must have either bitten or exposed a human or vaccinated family pet I.E. - a raccoon or a family dog bitten by a raccoon Reports on tested animals are sent to the provider/submitter, local regional epidemiology, and state epidemiology Stress the importance of pet vaccinations – including cats if outdoors DO NOT monitor for surveillance – the USDA-Wildlife Services handles this service Public Health focus Human Illness

6. Concern in TN Raccoon Rabies

7. Unicoi Marion Hamilton Bradley Polk Grundy Sequatchie Bledsoe Rhea Meigs McMinn Monroe LoudonBlount Roane Sevier Knox Morgan Anderson Scott Campbell Claiborne Grainger Union Hamblen Jefferson Cocke Pickett Overton Fentress Dekalb Warren Van Buren White Putnam Cumberland Hancock Hawkins Greene Washington Sullivan Carter Johnson East TN counties Raccoon rabies 2003 – Nov 26, 2007 Slide provided by John Dunn

10. Time Canine Rabies # of Domestic Animals received for testing Incidence of Raccoon and Skunk Rabies # of Domestic Biting Animals Reported Epidemiology Involvement Variables Over Time Graph

11. # of Domestic animals submitted for testing Epidemiology to screen all submissions Limit testing to animals that have demonstrated a true risk for rabies transmission Organized checklist to perform a risk-based assessment to identify animals with true risk of transmitting rabies Epidemiology over-worked and cannot keep up with demand B R B The lab is expected to test all specimens submitted without asking questions Epidemiology’s job is to protect the public so we only become involved in cases that are positive. “I am not going to be the one who gets sued because the animal was not tested and someone died.” The lab is losing money because of un-restricted and un- necessary testing Epidemiology time and resources are compromised limiting their ability to achieve the fundamental solution Shifting-the- Burden

12. Program Goals: 1) To create a consistent Rabies/animal bite investigation protocol allowing for better risk assessment and communication among all stakeholders. 2) To reduce the number of domestic animals submitted for laboratory testing to those animals with a true risk of infection. Outcome Objective: By June 30, 2009, reduce the number of domestic animal heads submitted for testing by 50% of the previous year (July 1, 2007 to June 30, 2008). Determinant: The number of domestic animal heads submitted for rabies testing at Knoxville Regional Laboratory. Focusing Question: Why are so many domestic animal heads submitted for rabies testing?

13. 1. By February 28, 2009, a common case investigation protocol will be ready for implementation. Monthly meeting of all stakeholder representatives 2. By April 30, 2009, all stakeholders will be educated as to the current epidemiology of rabies in Tennessee, the current literature regarding the biology of rabies virus transmission, and the use of the new case investigation protocol. In-service/training for all animal control partners, all county environmentalists, and all animal shelter personnel. Continuing Education Seminars for veterinarians 3. By June 30, 2009, stakeholders will create a handout or brochure for the community that outlines the social, legal, and medical aspects of a possible rabies exposure and provides information on where to seek assistance in the event of an animal bite or exposure. Yearly rabies vaccination clinics Program Objectives

14. Current Status Began monthly meetings in August of 2008 As of January 2009 meeting: outlined all stakeholders roles in an investigation established criteria for home observation determined that a public health representative will be contacted in the event a biting animal is ill and requires euthanasia and testing Working with one county as the process evolved: Reduced numbers of heads by 63% Cost savings for the laboratory ~ $ 3,480 Beginning work on education materials for stakeholders and public

15. National Environmental Health Services This project meets 6 of the 10 essential services: Inform, Educate, and Empower Assure a competent workforce Link people to needed services Enforce Laws and Regulations Develop Policies and Plans Mobilize Community Partnerships

16. Questions???