Perceptions and Practices of Mass Bat Exposure Events in the Setting of Rabies Among U.S. Public Health Agencies

Current guidelines in the setting of exposures to potentially rabid bats established by the Advisory Committee on Immunization Practices (ACIP) address post‐exposure prophylaxis (PEP) administration in situations where a person may not be aware that a bite or direct contact has occurred and the bat is not available for diagnostic testing. These include instances when a bat is discovered in a room where a person awakens from sleep, is a child without an adult witness, has a mental disability or is intoxicated. The current ACIP guidelines, however, do not address PEP in the setting of multiple persons exposed to a bat or a bat colony, otherwise known as mass bat exposure (MBE) events. Due to a dearth of recommendations for response to these events, the reported reactions by public health agencies have varied widely. To address this perceived limitation, a survey of 45 state public health agencies was conducted to characterize prior experiences with MBE and practices to mitigate the public health risks. In general, most states (69% of the respondents) felt current ACIP guidelines were unclear in MBE scenarios. Thirty‐three of the 45 states reported prior experience with MBE, receiving an average of 16.9 MBE calls per year and an investment of 106.7 person‐hours annually on MBE investigations. PEP criteria, investigation methods and the experts recruited in MBE investigations varied between states. These dissimilarities could reflect differences in experience, scenario and resources. The lack of consistency in state responses to potential mass exposures to a highly fatal disease along with the large contingent of states dissatisfied with current ACIP guidance warrants the development of national guidelines in MBE settings.     

Evaluating the public health response to a mass bat exposure—Wyoming, 2017

Mass bat exposures (MBEs) occur when multiple people are exposed to a bat or a bat colony, often over an extended period. In August 2017, a public health investigation was started in response to an MBE that occurred during May–August 2017 at a national park research station in Wyoming. We identified 176 people who had slept primarily in two lodges (Lodges A and B) at the research station, and successfully contacted 165 (93.8%) of these individuals. Risk assessments (RAs) were administered to all 165 individuals to determine degree and type of exposures to bats (e.g., biting or scratching). Exposure status for research station guests was classified as “non‐exposed,” “low risk” or “high risk,” and counselling was provided to guide post‐exposure prophylaxis (PEP) recommendations. Prior to public health notification and intervention, 19 persons made the decision to pursue PEP. The healthcare‐seeking behaviours of this group were taken to represent outcomes in the absence of public health intervention. (These persons received a RA, and their risk classification was retrospectively assigned.) Approximately 1–2 weeks after conducting the RAs, we conducted a follow‐up survey to determine whether recommendations regarding PEP were ultimately followed. The proportion of individuals that unnecessarily pursued PEP was higher among the 19 individuals that sought health care prior to receiving the RA (p < 0.00001). Among those receiving the RA first, all persons classified as high risk followed public health guidance to seek PEP treatment. Despite this, upon re‐interview, only 21/79 (26.6%) of guests could accurately recall their risk classification, with most people (55.7%) overestimating their risk. Study findings demonstrate that early public health interventions such as RAs can reduce unnecessary use of PEP and that messaging used during rabies counselling should be clear.     

Post‐exposure rabies prophylaxis for mass bat exposures: Case series and systematic review

To assess and describe the use of rabies post‐exposure prophylaxis (PEP) related to mass bat exposures (MBEs) in the literature and in the state of Rhode Island. Data on MBE events occurring between 2010 and 2016 from the Rhode Island Department of Health (RIDOH) were reviewed to determine PEP usage. For comparison, a systematic review was also performed by searching PubMed, EMBASE, Cochrane Library and Web of Science using the keywords ‘rabies,’ ‘bat’ and ‘exposure.’ There were three MBE events in Rhode Island between 2010 and 2016 in which groups of individuals were asleep during the potential exposure. As a result, RIDOH provided PEP to those involved in the event. In a systematic review of 12 published reports, a variety of settings were involved in MBEs: camping sites, a domestic flight, a neonatal intensive care unit and dormitories. The number of potential rabies exposures ranged from five to 1,429 people. PEP recommendations for assessed persons ranged from 0% to 100% across events (median 21%). The variation in PEP recommendations following a MBE may be dependent on medical need, past precedent or preference. Federal guidance for MBE is needed to add clarity and to minimize the variability in PEP recommendations for such events in the future.     

Free‐Roaming Dogs in Nepal: Demographics,Health and Public Knowledge,Attitudes and Practices

In Nepal, most dogs are free to roam and may transmit diseases to humans and animals. These dogs often suffer from malnutrition and lack basic health care. Minimal information is available about their demographics and about public attitudes concerning dogs and diseases. We carried out a study in Chitwan District (central Nepal), to collect baseline data on free‐roaming owned dog demographics, assess knowledge, attitudes and practices of dog owners concerning dogs and rabies, evaluate rabies vaccination coverage and anthelmintic treatment of dogs, measure dogs' response to rabies vaccination and assess dog health through body condition scores and parasites. We conducted household interviews with owners of free‐roaming female dogs (n = 60) and administered dogs with rabies vaccination and anthelmintics. Dog owners regularly fed free‐roaming dogs but provided minimal health care; 42% of respondents did not claim ownership of the dog for which they provided care. We collected skin, faecal and blood samples for parasite identification and for measuring rabies virus‐specific antibodies. Ninety‐two per cent of dog owners were aware of the routes of rabies virus transmission, but only 35% described the correct post‐exposure prophylaxis (PEP) following a dog bite. Twenty‐seven per cent of the dogs had measurable rabies virus‐specific antibody titres and 14% had received anthelmintics in the previous year. Following rabies vaccination, 97% of dogs maintained an adequate antibody titre for ≥6 months. Most dogs appeared healthy, although haemoprotozoans, endoparasites and ectoparasites were identified in 12%, 73% and 40% of the dogs, respectively. Poor skin condition and parasite load were associated. Seventy‐four per cent of the females had litters in 1 year (mean litter size = 4.5). Births occurred between September and February; we estimated 60% mortality in puppies. We concluded that vaccination coverage, PEP awareness and anthelmintic treatment should be emphasized in educational programmes focussed on animal welfare, veterinary and public health.     

Determinants of health seeking behaviour following rabies exposure in Ethiopia

The objective of this study was to identify factors that determine medical treatment seeking behaviour following potential rabies exposure after being bitten by a suspected dog and the likelihood of compliance to receive sufficient doses of post‐exposure prophylaxis after the visit to a health centre visit. A detailed survey based on case investigation was conducted on suspected rabid dog bite cases in three areas of Ethiopia. Two multivariable logistic regression models were created with a set of putative variables to explain treatment seeking and compliance outcomes. Based on the registered bite cases at each health centre and the set of unregistered bite cases derived by contact tracing, 655 bite victim cases were identified to have occurred between September 2013 and August 2014. Of these evaluated bite incidences, 465 cases were considered to have been caused by a potentially rabid dog. About 77% of these suspected rabid dog bite victims visited a health centre, while 57% received sufficient doses of PEP. The overall likelihood of seeking medical services following rabies exposure was higher for people bitten by dogs of unknown ownership, where the bite was severe, being bitten on the leg, spend of more than 100 USD per month and where the victim lived close to the nearest health centre, while the likelihood of receiving sufficient doses of PEP was sensitive to monthly spending and distance to health centre. However, the evaluated factors did only explain a part of the variation among the three districts. The district in which victims lived appeared to have a relevant influence on the likelihood of seeking medical treatment but did not improve the prediction on the likelihood of treatment compliance. Given the insights obtained from this study, improvements in the rural districts with regard to accessibility of post‐exposure prophylaxis delivering health centres in shorter distance could improve health seeking behaviour. In addition, in rural districts, majority of exposed persons who seek medical treatment tend to comply with treatment regimen, indicating that the promotion of medical treatment through awareness creation campaigns could be beneficial.     

Recurrent Temporary Paralysis Reported After Human Rabies Post‐Exposure Prophylaxis

Adverse events can occur after rabies post‐exposure prophylaxis (PEP), and linkage to causality is often difficult to determine. We report a case of recurrent temporary paralysis that began immediately after the initiation of rabies PEP in a man exposed to a bat. The recurrent temporary paralysis first occurred in the patient after his initial dose and then again after day 3 of his rabies PEP. The PEP was terminated prior to a serologic response. The patient continued to experience numerous discrete episodes of temporary paralysis for over two years.     

Meeting the urgent need for rabies education in Haiti

The highest rate of human rabies deaths reported in the Americas is in Haiti, and most of these deaths result from rabies virus infections that occur after individuals are bitten by infected dogs and do not receive rabies post‐exposure prophylaxis. One barrier to rabies prevention in Haiti is a lack of knowledge about this disease among healthcare professionals and community members. During the past 4 years, The US Centers for Disease Control and Prevention has collaborated with public health officials and partners to develop, test and refine educational materials aimed at filling this need for rabies education. This report summarizes the use of feedback from knowledge, attitudes and practises surveys; key informant interviews; and focus groups to develop culturally appropriate rabies prevention materials for community members, health officials, clinicians, laboratory professionals, veterinary professionals, government officials and national and local district leaders about ways to prevent rabies. These formative research methods were critically important in ensuring that the materials would be culturally appropriate and would stand the greatest likelihood of motivating Haitians to protect themselves from rabies. Centers for Disease Control and Prevention is using lessons learned in Haiti to develop and test materials in other countries with high rates of canine rabies.     

Public health response to an imported case of canine melioidosis

Melioidosis in humans presents variably as fulminant sepsis, pneumonia, skin infection and solid organ abscesses. It is caused by Burkholderia pseudomallei, which in the United States is classified as a select agent, with “potential to pose a severe threat to both human and animal health, to plant health or to animal and plant products” (Federal Select Agent Program, http://www.selectagents.gov/ , accessed 22 September 2016). Burkholderia pseudomallei is found in soil and surface water in the tropics, especially South‐East Asia and northern Australia, where melioidosis is endemic. Human cases are rare in the United States and are usually associated with travel to endemic areas. Burkholderia pseudomallei can also infect animals. We describe a multijurisdictional public health response to a case of subclinical urinary B. pseudomallei infection in a dog that had been adopted into upstate New York from a shelter in Thailand. Investigation disclosed three human contacts with single, low‐risk exposures to the dog's urine at his residence, and 16 human contacts with possible exposure to his urine or culture isolates at a veterinary hospital. Contacts were offered various combinations of symptom/fever monitoring, baseline and repeat B. pseudomallei serologic testing, and antibiotic post‐exposure prophylaxis, depending on the nature of their exposure and their personal medical histories. The dog's owner accepted recommendations from public health authorities and veterinary clinicians for humane euthanasia. A number of animal rescue organizations actively facilitate adoptions into the United States of shelter dogs from South‐East Asia. This may result in importation of B. pseudomallei into almost any community, with implications for human and animal health.     

Human Exposure to Rabid Free‐Ranging Cats: A Continuing Public Health Concern in Pennsylvania

Rabid free‐ranging cats have been a public health concern in Pennsylvania since raccoon variant rabies first was recognized in the state in the early 1980s. Over the last decade, between 1.5 and 2.5% of cats submitted to Pennsylvania's state laboratories for rabies testing have been positive. In this report, we describe the extent of rabies in free‐ranging cats in Pennsylvania. We also present two examples of human exposure to rabid free‐ranging cats that occurred in Pennsylvania during 2010–2011 and the public health actions taken to address rabies exposure in the humans and animals. We then describe the concerns surrounding the unvaccinated and free‐ranging cat population in Pennsylvania and possible options in managing this public and animal health problem.     

Fighting Rabies in Eastern Europe,the Middle East and Central Asia ‐ Experts Call for a Regional Initiative for Rabies Elimination

MEEREB is an informal network of rabies experts from the Middle East, Eastern Europe and Central Asia, seeking to eliminate rabies from the region. They met for the second time to review the current rabies situation, both globally and in their respective countries, highlighting current rabies control problems and potential solutions. Success stories in Latin America, in Western Europe, in some Asian countries, as well as in Croatia and Serbia prove that elimination of human rabies is achievable in the MEEREB region. It requires political willingness and cooperation of all stakeholders, including Ministries of Health and of Agriculture; adequate management of animal bites through post‐exposure prophylaxis; pre‐exposure prophylaxis for populations at high risk of rabies exposure, animal vaccination and humane control of stray dog populations. MEEREB members called for a regional initiative for rabies elimination in Eastern Europe and the Middle East. They are confident that the elimination of human rabies of canine origin can be achieved in the region through adopting a One Health approach, and that campaigns for rabies elimination will have significant benefit for public health, including strengthening the structure for control of other zoonoses.     

Barriers to innovation in human rabies prophylaxis and treatment: A causal analysis of insights from key opinion leaders and literature

Rabies is an essentially 100% fatal, zoonotic disease, caused by Lyssaviruses. Currently, the disease is vaccine‐preventable with pre‐ and post‐exposure prophylaxis (PrEP and PEP). Still, rabies virus is estimated to cause up to 60,000 human deaths annually, of which the vast majority occurs in rural Asia and Africa, due to the inaccessibility of prophylaxis and non‐existence of treatment. Despite these unmet clinical needs, rabies control mainly focuses on the sylvatic reservoir and drug innovation receives relatively little attention compared to other neglected tropical diseases (NTDs). As such, the lag of innovation in human rabies prophylaxis and treatment cannot be explained by limited return on investment alone. Strategies countering rabies‐specific innovation barriers are important for the acceleration of innovation in human rabies prophylaxis and treatment. Barriers throughout society, science, business development and market domains were identified through literature review and 23 semi‐structured interviews with key opinion leaders worldwide. A subsequent root cause analysis revealed causal relations between innovation barriers and a limited set of root causes. Finally, prioritization by experts indicated their relative importance. Root causes, which are fundamental to barriers, were aggregated into four types: market and commercial, stakeholder collaboration, public health and awareness, and disease trajectory. These were found in all domains of the innovation process and thus are relevant for all stakeholders. This study identifies barriers that were not previously described in this specific context, for example the competition for funding between medical and veterinary approaches. The results stress the existence of barriers beyond the limited return on investment and thereby explain why innovation in human rabies medication is lagging behind NTDs with a lower burden of disease. A re‐orientation on the full spectrum of barriers that hinder innovation in rabies prophylaxis and treatment is necessary to meet unmet societal and medical needs.     

Rabies postexposure prophylaxis. Human and domestic animal considerations.

The emphasis on rabies control and prevention in the United States seems to be a function of our perception of proximity of the threat. Wildlife rabies epizootics within a state may be of little concern to the uninformed urban dweller. Additionally, many parts of the western United States are free of terrestrial rabies; were it not for the presence of bat rabies, people in those areas would likely interpret rabies control as a minor public health concern. It is essential that federal, state, and local public health programs emphasize the importance of rabies control through activities that include rabies education, sponsorship of legislated requirements for domestic animal vaccination, support for local animal control programs, and the promotion of recommendations that encourage the appropriate use of PEP. We are almost guaranteed that rabies is going to remain a major public health issue well into the next century because of expanding wildlife rabies epizootics, identification of new rabies viral variants with increased public health concern, emotional and legal concerns associated with rabies exposure, and increasing national cost associated with rabies control and prevention. Nevertheless, the development of new laboratory technology that allows an understanding of the epidemiologic nature of the rabies virus based on an evolving genetic history and the interrelationship with wildlife reservoirs should allow access to valuable tools for rabies control. When combined with programs using new developments in oral rabies vaccine that can immunize whole populations of wildlife reservoirs, that technology offers encouragement in our effort to control one of the diseases of antiquity.     

Knowledge of Rabies Prevention in Vietnamese Public Health and Animal Health Workers

Rabies is an invariably fatal, but preventable zoonotic disease. Despite a national programme for its prevention and control, the number of rabies associated deaths in Vietnam has increased in recent years. A cross‐sectional survey was undertaken in 2012 to assess and compare the knowledge, awareness and practices of 189 public health workers (PHW) and animal health workers (AHW) attending a joint training course for professionals from provinces in northern Vietnam with the highest number of deaths from rabies. Questionnaires facilitating self‐evaluation were provided, and total knowledge scores were calculated (maximum 38 points) and categorized into: ‘high’ (>30 points), ‘moderate’ (21–30) and ‘low’ (<21). The response rate was 100%, and among the 189 participants, 56% were PHW compared to 44% who were AHW. Although most respondents knew rabies could be transmitted through the bite of an animal, most commonly a dog, and that rabies is a preventable disease, significant differences between groups were identified. Major areas included poor knowledge of common rabies reservoirs, wound management and guidance on post‐exposure prophylaxis. Overall, the total mean knowledge scores for PHW was significantly higher (P = 0.011) compared to those for AHW, but both scores fell within the ‘moderate’ knowledge range. However, proportionately more PHW than AHW achieved ‘high’ knowledge scores (P = 0.0098). To our knowledge this is the first published study to simultaneously assess the knowledge and awareness of animal health and public health professionals attending joint training activities aimed at strengthening rabies prevention and control. To ensure effective prevention and control of rabies requires that AHW and PHW not only coordinate and collaborate, but have a common knowledge and understanding of rabies prevention and control measures. This study provides important baseline data in a relatively unexplored area of research that can focus future interventions and research.     

Animal bite epidemiology and surveillance for rabies postexposure prophylaxis

OBJECTIVES: To understand the epidemiology of animal bites and exposure, evaluate the animal exposure reporting system for surveillance of rabies postexposure prophylaxis (PEP), and identify opportunities to reduce PEP. DESIGN: Period prevalence survey. STUDY POPULATION: Pennsylvania residents in 1995. PROCEDURE: Data from animal bite reports from Pennsylvania county health offices were summarized for 1995. Animal bite incidences for the state, counties, various age groups, and various population densities were calculated. Animal species, treatment, location of wounds, and PEP recommendations were evaluated for exposures. RESULTS: More than 16,000 animal-related potential rabies exposures were reported from 65 of 67 counties in Pennsylvania. The highest incidence was in children less than 5 years old (324/100,000). Of the 75% of victims requiring wound treatment, 50% received antimicrobials, 29% received a tetanus toxoid, and 19% had wounds sutured, were admitted to hospitals, or were referred for plastic surgery. Although 75% of exposures were to dogs, victims exposed to cats were 6 times as likely to receive PEP (relative risk, 6.1; 95% confidence interval, 5.1 to 7.4). Thirty percent of 556 PEP were given for exposures to dogs, 44% for cats, 7% for raccoons, 4% for bats, 2.5% for squirrels, 2.1% for groundhogs, 2% for foxes, and 8% for exposures to other species. Fifty-nine percent of owned dogs were up-to-date on rabies vaccinations compared with 41% of owned cats. CONCLUSION: Interventions, such as dog bite prevention education, vaccination of pets against rabies, appropriate use of PEP, and reduction of feral cat populations, should be instituted, enhanced, or better enforced in communities.     

Knowledge,Attitudes and Practices of Primary Care Physicians in the Franche‐Comte Region (France) Regarding the Risk of Rabies

Rabies remains a public health concern and is associated with a mortality rate of nearly 100%. An observational survey was undertaken in 2010 to assess the knowledge, attitudes and practices of primary care physicians (PCPs) in our area regarding the risk of rabies. Standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche‐Comté region (eastern France), requesting their voluntary and anonymous participation. The questionnaires requested socio‐demographic details and self‐evaluation. Seven clinical situations were selected to assess the attitudes of physicians. The response rate was 38.5%. Most of the PCPs were based in rural and semi‐rural areas, 76% knew where their nearest rabies centre was located and 75% of them claimed their knowledge of the risk of rabies was poor. While most of them (>80%) knew which animals transmitted the disease as well as the severity criteria for bites, only 12% knew that there was no contraindication for the rabies vaccine in the event of exposure to the disease. Responses to the seven clinical situations showed that most of them did not know the precise indication for the rabies vaccine and rabies immunoglobulin. Primary care physicians are usually aware of the risk of rabies, but their knowledge of how to manage rabies exposure and prevention often requires updating. The health authorities should provide more detailed information to PCPs and to the general population about the risk of rabies.     

Equine chlamydiosis—An emerging infectious disease requiring a one health surveillance approach

Psittacosis is a rare but potentially fatal zoonosis caused by Chlamydia psittaci, an organism that is typically associated with bird contact. However C. psittaci is capable of infecting other non‐avian hosts, such as horses, sheep, cattle and goats. Stud staff and veterinarians have significant exposure to parturient animals and reproductive materials in their routine work. To investigate the zoonotic potential associated with the emergence of C. psittaci as an abortifacient agent in horses, we established a programme of joint human and animal surveillance in a sentinel horse‐breeding region in Australia. This programme comprised cross‐notification of equine cases to public health agencies, and active follow‐up of known human contacts, including stud workers, foaling staff, veterinarians and laboratory staff. We identified no confirmed cases of acute psittacosis despite intensive surveillance and testing of heavily exposed contacts; however, further work in the area is needed.