Persistence of elevated rabies prevention costs following post-epizootic declines in rates of rabies among raccoons (Procyon lotor)

Determining the benefits to cost relationships among different approaches to rabies control and prevention has been hindered by the inherent temporal variability in the dynamics of disease among wildlife reservoir hosts and a tangible and objective measure of the cost of rabies prevention. A major and unavoidable component of rabies prevention programs involves diagnostic testing of animals and the subsequent initiation of appropriate public health responses. The unit cost per negative and positive diagnostic test outcome can be reasonably estimated. This metric when linked to methodologies subdividing the epizootic process into distinct temporal stages provided the requisite detail to estimate benefits derived from rabies control strategies. Oral rabies vaccine (ORV), for prevention of the raccoon-associated variant of rabies, has been distributed in Ohio and adjoining states in an effort to develop an immune barrier to the westward spread of epizootic raccoon rabies. The costs of ORV delivery have been quantified. Herein, the cost structures required to assess the benefits accrued by prevention were developed. A regression model was developed effectively predicting (r² = 0.70) the total number of rabies diagnostic tests performed by 53 counties in five northeastern (NE) states from 1992 to 2001. Five temporal stages sufficed to capture the range of variability in the raccoon rabies epizootic process. Unit costs, dollars per diagnostic test outcome, were calculated for negative and positive results from published reports. Ohio counties were matched to NE counties based on similar socioeconomic characters. A “pseudo-epizootic” of raccoon rabies was introduced into Ohio and the costs savings from ORV were derived as the excess costs imposed by epizootic spread throughout the state. At 46 km/year (range modeled, 30–60 km/year), the pseudo epizootic spread, and reached the enzootic stage, in all Ohio counties by year 13 (range modeled, 11–17 years). Cumulative excess costs for Ohio ranged between $11 and $21 million; counties of low socioeconomic status experienced the greatest relative excess costs. The costs for rabies prevention activities reached apices during the epizootic stage of raccoon rabies (2.7–10.8 times baseline) an unforeseen finding indicated elevated costs persisted (1.7–7.2 times baseline) into the enzootic stage.     

A statewide,cross-sectional evaluation of the knowledge and level of concern of rabies among South Carolina residents

Animal rabies cases have increased steadily in South Carolina (SC) for the past decade. An understanding of the population's awareness and understanding of the disease is needed to tailor public health interventions. A marketing list-serv of SC residents' email addresses was used to recruit anonymous respondents for a Knowledge Attitudes and Practices (KAP) electronic survey. A total 516 South Carolinians completed the 31-question survey. Quantile regression and a Pearson's correlation evaluated potential associations between respondent's rabies knowledge and their attitudes and practices. Knowledge was assessed on topics of rabies biology, state animal case counts and rabies pet-related laws. Level of concern and level of knowledge were positively correlated. Additionally, statewide hotspot analysis revealed geographic areas warranting targeted public health interventions; counties with low public concern juxtapositioned with high animal rabies case counts. This study demonstrates the utility of statewide KAPs to gauge populations rabies perception and related preventative actions to tailor appropriate educational programs to limit human-animal rabies exposures.     

Use of Aspiration Method for Collecting Brain Samples for Rabies Diagnosis in Small Wild Animals

In developing countries such as Brazil, where canine rabies is still a considerable problem, samples from wildlife species are infrequently collected and submitted for screening for rabies. A collaborative study was established involving environmental biologists and veterinarians for rabies epidemiological research in a specific ecological area located at the Sao Paulo State, Brazil. The wild animals’ brains are required to be collected without skull damage because the skull’s measurements are important in the identification of the captured animal species. For this purpose, samples from bats and small mammals were collected using an aspiration method by inserting a plastic pipette into the brain through the magnum foramen. While there is a progressive increase in the use of the plastic pipette technique in various studies undertaken, it is also appreciated that this method could foster collaborative research between wildlife scientists and rabies epidemiologists thus improving rabies surveillance.     

Rabies, an emerging disease in Korea

Since the first rabies case was reported in a dog in 1907, the disease was enzootic up to 1975 in Korea. After a steady decrease in the number of rabies cases from 1976 to 1984, no case was reported for 8 years from 1985 to 1992. Then, a resurgence of the disease was noted in 1993, and a continuous increase of rabies cases was observed during the following years. This report provides information on rabies in South Korea during the reemerging period 1993-2003. A total of 364 rabies cases in five different animal species and five deaths in human beings as a result of rabies were reported. Cattle and dogs accounted for 46.4% and 40.4% of total animal cases, respectively, and raccoon dogs commanded an overwhelming majority (44/48) of rabies cases in wildlife animal species. All animal and human rabies cases occurred only in two provinces, Gyeonggi and Gangwon; majority of them in two counties of Gyeonggi and one county of Gangwon province that border the demilitarized zone. From the three counties, the disease continued to expand to the other areas of the two provinces. The average monthly frequency of animal rabies cases during the 11-year period peaked in January, and the incidence was highest during winter. There were three major rabies outbreaks in animals and the number of animal rabies cases increased with time. Data indicate that the temporal patterns were attributable to the ethology of raccoon dogs in the areas of outbreak.     

Surveillance of Human Rabies by National Authorities – A Global Survey

Effective prevention of deaths due to human rabies is currently hampered by a lack of understanding of the scale of the problem, and the distribution of both animal and human cases across countries, regions and continents. Unfortunately, despite the severity of the disease, accurate data on which to assess these questions and to prioritize and direct public health interventions are not available for many parts of the world. This survey sought to understand the current global situation regarding the surveillance of human rabies. Data were collected from 91 countries across all continents and all categories of human rabies risk, generating the most complete and representative global data set currently available. Respondents were asked key questions about whether human rabies was a notifiable disease, how the surveillance system for human rabies operated and whether the respondent considered that the surveillance system was working effectively. Across the 91 countries from which data were collated, human rabies was a notifiable disease in all but eight. Despite international guidance, surveillance systems were very varied. Even where rabies is a notifiable disease, many countries had surveillance system judged to be ineffective, almost all of these being high and moderate rabies risk countries in Africa and Asia. Overall, 41% of the population covered by this survey (around 2.5 billion people) live in countries where there is no or ineffective rabies surveillance. The lack of robust surveillance is hindering rabies control efforts. However, whilst worldwide rabies surveillance would be improved if rabies were notifiable in all countries, many other challenges to the implementation of effective global human rabies surveillance systems remain.     

Epizootic of rabies in raccoons in Maryland from 1981 to 1987.

The epizootic of rabies in raccoons entered Maryland in 1981 and systematically moved through the state affecting raccoons in all counties except those of the lower Eastern Shore. A precoded surveillance form was provided to all county and city health departments and data were requested for each animal head submitted for testing for the year 1985. The disease persisted and, in 1987, all counties previously reporting rabies in raccoons also had documented cases in other species. The incidence of rabies in raccoons increased in late winter and peaked in March. Most human exposures occurred during daylight hours and in private yards. Agricultural areas were similarly affected by rabid animals. Analysis of vaccination status of animals exposed to rabid animals gave estimations of statewide vaccination rates for dogs (70%) and cats (28%). The danger of rabies in cats was emphasized by the large number of animals exposed by each rabid cat. The spillover of rabies in raccoons to other species persisted in all jurisdiction through 1992, with periodic upsurges of disease at 3- to 4-year intervals as the raccoon population is replenished. Rabies was not diagnosed in any human beings.     

Increased detection of rabies virus in bats in Ceará State (Northeast Brazil) after implementation of a passive surveillance programme

The intensification of dog, cat and livestock vaccination campaigns significantly reduced rabies cases in humans and domestic animals in Ceará State, Brazil. However, sylvatic animals—bats (order Chiroptera), wild canids, raccoons and non‐human primates— remain as reservoirs for the virus. Our hypothesis is that surveillance and monitoring of rabies virus in bats, especially passive surveillance, is of fundamental importance, besides the implementation of health education and strengthening of surveillance actions in humans exposed to aggressions. Thus, we assessed the occurrence of rabies virus in animals focusing on bats, before and after launching of the Sylvatic Rabies Surveillance Program in 2010. Surveillance data from the 184 municipalities of Ceará State were analysed, collected during the periods 2003–2010 (active surveillance) and 2011–2016 (passive surveillance), respectively. A total of 13,543 mammalian samples were received for rabies diagnosis from 2003 to 2016. Of these, 10,960 were from dogs or cats (80.9%), 1,180 from bats (8.7%), 806 from other sylvatic animals (foxes, marmosets, raccoons; 6.0%) and 597 from herbivores (cattle, goats, sheep, equines, pigs; 4.4%). A total of 588 (4.3%) samples were positive for rabies. About 8.4% (99/1,180) of the bat samples were infected with rabies virus, 92 (92.9%) of these were from non‐haematophagous bat species and 7 (7.1%) from haematophagous species. The number of bat samples received and infection rates increased considerably, after a shift from active surveillance (9/355 [2.5%] samples positive), to passive surveillance (90/825 [10.9%] samples positive). Surveillance of rabies virus in bats is fundamental for human and domestic animal health in Ceará State. Bats have to be considered as targets in surveillance and control programmes. Virus lineages should be characterized to increase knowledge on transmission dynamics of sylvatic rabies virus to domestic animals and the human population, and to provide additional evidence for planning and implementation of improved control measures.     

Review of Rabies Epidemiology and Control in South,South East and East Asia: Past,Present and Prospects for Elimination

Rabies is a serious public health problem in Asia. It causes substantial animal welfare, economic and human health impacts, with approximately 39 000 human deaths each year. Domestic dogs are the main reservoir and source of rabies in Asia. Common constraints for the control of rabies in the countries of Asia include inadequate resources; lack of political commitment to control programs; lack of consensus on strategy; weak intersectoral coordination and inadequate management structure; insensitive surveillance systems; limited accessibility to modern rabies vaccine and supply problems; lack of public awareness and public cooperation; and the existence of myths and religious issues. In this review, we summarize the epidemiology of rabies in both human and animals in each South and South East Asian country, the past and current approaches to control and the prospect for rabies elimination. We conclude that defining the cost of rabies to society and communicating this to decision‐makers might be the key to achieving such an advance.     

Surveillance and control of rabies in La Reunion,Mayotte, and Madagascar

Mayotte and La Reunion islands are currently free of animal rabies and surveillance is performed by the French Human and Veterinary Public Health Services. However, dog rabies is still enzootic in Madagascar with 4 to 10 confirmed human cases each year. The number of antirabies medical centres in Madagascar is still scarce to provide easy access to the local population for post-exposure rabies prophylaxis. Furthermore, stray dog populations are considerable and attempts to control rabies by mass campaigns of dog vaccination have not received sufficient attention from the national health authorities. To address these challenges, an expanded program to control rabies needs to be initiated by the Malagasy authorities.     

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.     

Canine Rabies in Australia: A Review of Preparedness and Research Needs

Australia is unique as a populated continent in that canine rabies is exotic, with only one likely incursion in 1867. This is despite the presence of a widespread free‐ranging dog population, which includes the naturalized dingo, feral domestic dogs and dingo‐dog cross‐breeds. To Australia's immediate north, rabies has recently spread within the Indonesian archipelago, with outbreaks occurring in historically free islands to the east including Bali, Flores, Ambon and the Tanimbar Islands. Australia depends on strict quarantine protocols to prevent importation of a rabid animal, but the risk of illegal animal movements by fishing and recreational vessels circumventing quarantine remains. Predicting where rabies will enter Australia is important, but understanding dog population dynamics and interactions, including contact rates in and around human populations, is essential for rabies preparedness. The interactions among and between Australia's large populations of wild, free‐roaming and restrained domestic dogs require quantification for rabies incursions to be detected and controlled. The imminent risk of rabies breaching Australian borders makes the development of disease spread models that will assist in the deployment of cost‐effective surveillance, improve preventive strategies and guide disease management protocols vitally important. Here, we critically review Australia's preparedness for rabies, discuss prevailing assumptions and models, identify knowledge deficits in free‐roaming dog ecology relating to rabies maintenance and speculate on the likely consequences of endemic rabies for Australia.     

A Large‐scale,Rapid Public Health Response to Rabies in an Organ Recipient and the Previously Undiagnosed Organ Donor

This article describes and contrasts the public health response to two human rabies cases: one organ recipient diagnosed within days of symptom onset and the transplant donor who was diagnosed 18 months post‐symptom onset. In response to an organ‐transplant‐related rabies case diagnosed in 2013, organ donor and recipient investigations were conducted by multiple public health agencies. Persons with potential exposure to infectious patient materials were assessed for rabies virus exposure. An exposure investigation was conducted to determine the source of the organ donor's infection. Over 100 persons from more than 20 agencies spent over 2700 h conducting contact investigations in healthcare, military and community settings. The 564 persons assessed include 417 healthcare workers [5.8% recommended for post‐exposure prophylaxis (PEP)], 96 community contacts (15.6% recommended for PEP), 30 autopsy personnel (50% recommended for PEP), and 21 other persons (4.8% recommended for PEP). Donor contacts represented 188 assessed with 20.2% recommended for PEP, compared with 5.6% of 306 recipient contacts recommended for PEP. Human rabies cases result in substantial use of public health and medical resources, especially when diagnosis is delayed. Although rare, clinicians should consider rabies in cases of encephalitis of unexplained aetiology, particularly for cases that may result in organ donation.     

A Conceptual Model for the Impact of Climate Change on Fox Rabies in Alaska, 1980–2010

The direct and interactive effects of climate change on host species and infectious disease dynamics are likely to initially manifest\ at latitudinal extremes. As such, Alaska represents a region in the United States for introspection on climate change and disease. Rabies is enzootic among arctic foxes (Vulpes lagopus) throughout the northern polar region. In Alaska, arctic and red foxes (Vulpes vulpes) are reservoirs for rabies, with most domestic animal and wildlife cases reported from northern and western coastal Alaska. Based on passive surveillance, a pronounced seasonal trend in rabid foxes occurs in Alaska, with a peak in winter and spring. This study describes climatic factors that may be associated with reported cyclic rabies occurrence. Based upon probabilistic modelling, a stronger seasonal effect in reported fox rabies cases appears at higher latitudes in Alaska, and rabies in arctic foxes appear disproportionately affected by climatic factors in comparison with red foxes. As temperatures continue a warming trend, a decrease in reported rabid arctic foxes may be expected. The overall epidemiology of rabies in Alaska is likely to shift to increased viral transmission among red foxes as the primary reservoir in the region. Information on fox and lemming demographics, in addition to enhanced rabies surveillance among foxes at finer geographic scales, will be critical to develop more comprehensive models for rabies virus transmission in the region.     

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.     

The Epidemiological Importance of Bats in the Transmission of Rabies to Dogs and Cats in the State of São Paulo,Brazil, Between 2005 and 2014

In Brazil, rabies control in dogs and cats was pioneered by the state of São Paulo with the adoption of the Pan American Health Organization recommendations for prophylaxis and control, which led to a reduction in rabies cases from 1994 onwards. As a result of these measures, the rabies virus (RABV) genetic lineage associated with dogs has not been found in the state since 1998, and all the cases in domestic animals reported since then have been caused by bat‐associated lineages of RABV. In the light of this, this study sought to investigate rabies cases in dogs and cats in the state of São Paulo between 2005 and 2014 and identify the associated transmission cycles by characterizing the RABV lineages responsible for these cases. Nine samples from dogs (n = 5) and from cats (n = 4) were collected between 2005 and 2014. The tenth animal, a rabid cat, was analysed by a different laboratory. The N gene nucleotide sequences obtained were analysed with the neighbor‐joining algorithm and Kimura 2‐parameter model using the MEGA 6 program. Phylogenetic analysis revealed that the genetic lineages identified in all the samples were those circulating in Brazilian bats. The findings of this study demonstrate that bats play an important role in the transmission of rabies to domestic animals in São Paulo state and that emphasis should be placed on the implementation of public policies to support surveillance of chiropterans for rabies.     

Towards incorporating spatial risk analysis for Salmonella sero-positivity into the Danish swine surveillance programme

An increased incidence of pork-related human salmonellosis in Denmark led to the development of a national control programme for Salmonella in Danish swine herds in 1993. The aim of the programme has been met and now the issue of cost-effectiveness is receiving greater attention. An appropriate way to address this is to bring a risk-based focus to the programme.

We describe a practical approach to risk-based surveillance through spatial risk assessment using serological and questionnaire data from 2280 herds in 1995. A mixed effects logistic regression model was fitted and both first- and second-order spatial properties of the random effects were investigated. We identified wet-feeding (OR: 0.64; 95% CI: 0.54–0.75) and SPF health status (OR: 0.65; 95% CI: 0.52–0.81) as protective factors for Salmonella sero-positivity. Purchasing feed (OR: 1.81; 95% CI: 1.61–2.04) was a risk factor. The west of the study area generally, and the north of Jutland in particular, experienced the greatest disease risk after controlling for the covariates. There was some evidence for spatial dependency between farms at distances of 6 km (95% CI: 2–35 km) on the Jutland peninsula.

We conclude that when farm location details are analysed in conjunction with routinely recorded surveillance information (such as that collected by the Danish swine Salmonella control programme) and targeted industry surveys (such as those conducted by slaughterhouse co-operatives), our knowledge of the behaviour of disease in animal populations is enhanced and this provides a more informed framework for designing efficient, risk-based surveillance strategies.     

Human-mediated foot-and-mouth disease epidemic dispersal: disease and vector clusters

Disease clusters were retrospectively explored at national level using a geo-referenced dataset from the 2001 Uruguayan Foot-and-Mouth Disease (FMD) epidemic. Disease location and time (first 11 epidemic weeks) were analysed across 250 counties (of which 160 were infected), without and with control for human mobility related factors (human population and road densities). The null hypothesis of random disease distribution over space and/or time was assessed with: (i) purely temporal; (ii) purely spatial; and (iii) space/time tests. At least within epidemic weeks 2 and 6, a principal disease cluster was observed in 33 contiguous counties (P < 0.01). Two secondary clusters, located at >100 km from each other, were also observed (P < 0.01). The purely spatial test that controlled for human population density identified two non-contiguous clusters (P < 0.01). Space and time analysis also revealed the same 33 counties as members of the principal cluster, of which 31 were also clustered when human population was controlled (P < 0.01). No clusters were reported by the spatial test when road density was assessed. The hypothesis that human mobility related factors autocorrelate with disease was empirically supported by two pieces of information: (i) removal of human population/road densities eliminated >93.9% of the counties included in the principal disease cluster; and (ii) statistically significant correlations (P < 0.05) were observed in the first three epidemic weeks between road density and the number of cases. Clusters where human population density was associated with 47% greater number of cases/sq. km than that of the principal cluster indicated possible roles as disease vectors (vector clusters). Selective control policy in vector clusters is recommended. Periodic (i.e. weekly) cluster and correlation analyses of both disease and other covariates may facilitate disease surveillance and help design space-specific control policy.