Epidemiology of rabies immune globulin use in paediatric and adult patients in the USA: a cross-sectional prevalence study

OBJECTIVES

To compare the epidemiology of paediatric and adult patients receiving rabies immune globulin (RIG).

DESIGN

Cross-sectional prevalence study.

SETTING

Eligible participants from the Symphony Integrated Dataverse presenting between 2013 and 2019.

PARTICIPANTS

All adult and paediatric patients with integrated claims and demographic data associated with RIG use from the Symphony Integrated Dataverse from 2013 to 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of diagnoses and procedures associated with paediatric and adult patient population based on frequency of International Classification of Diseases (ICD-9/ICD-10) and Current Procedural Terminology codes, respectively.

METHODS

We used mutual information to identify features that differentiate the paediatric from adult patient population. Prevalence ratios were calculated to compare adult and paediatric patients.

RESULTS

There were 79 766 adult and 20 381 paediatric patients who met the inclusion criteria. Paediatric patients had a 5.92-fold higher prevalence of 'open wounds to the head; neck; and trunk', 3.10-fold higher prevalence of 'abrasion or friction burn of face; neck; and scalp except eye; without mention of infection', 4.44-fold higher prevalence of 'open wound of scalp; without mention of complication' and 6.75-fold higher prevalence of 'laceration of skin of eyelid and periocular area | laceration of eyelid involving lacrimal passages'. Paediatric patients had a 3.83-fold higher prevalence of complex repairs compared with adult patients (n=157, 0.7% vs n=157, 0.2%, respectively).

CONCLUSIONS

Paediatric patients represent a significant proportion of the patient population receiving RIG, and are associated with higher prevalence of codes reporting repair of larger, more complex wounds in highly innervated anatomical regions. Dosing and administration of RIG must be informed by animal bite wound characteristics; clinicians should understand the differences between presentations in adults and children and treat accordingly.

Feline and Canine Rabies in New York State, USA

In New York State, domestic animals are no longer considered rabies vector species, but given their ubiquity with humans, rabies cases in dogs and cats often result in multiple individuals requiring post-exposure prophylaxis. For over a decade, the New York State rabies laboratory has variant-typed these domestic animals to aid in epidemiological investigations, determine exposures, and generate demographic data. We produced a data set that outlined vaccination status, ownership, and rabies results. Our data demonstrate that a large percentage of felines submitted for rabies testing were not vaccinated or did not have a current rabies vaccination, while canines were largely vaccinated. Despite massive vaccination campaigns, free clinics, and education, these companion animals still occasionally contract rabies. Barring translocation events, we note that rabies-positive cats and dogs in New York State have exclusively contracted a raccoon variant. While the United States has made tremendous strides in reducing its rabies burden, we hope these data will encourage responsible pet ownership including rabies vaccinations to reduce unnecessary animal mortality, long quarantines, and post-exposure prophylaxis in humans.

Rabies: Current Preventive Strategies

Desensitization to rabies is a result of successfully eliminating canine rabies in the United States, which occurred in 2007; however, the need for mandatory rabies vaccination in pets remains. Rabies cases are rare in comparison with other vaccine-preventable diseases in companion animals; however, because it is a zoonotic disease with the highest case fatality rate of any infectious disease demands the establishment of strict laws for disease prevention. Preventive strategies include addressing current concerns in consideration of disease surveillance, appropriate vaccination recommendations, and local regulations protecting public health.

EVALUATION OF ORAL RABIES VACCINATION: PROTECTION AGAINST RABIES IN WILD CAUGHT RACCOONS ( PROCYON LOTOR)

Oral rabies vaccination (ORV) is an effective tactic for wildlife rabies control, particularly for containment of disease spread along epizootic fronts. As part of the continuing evaluation of the ORV program in free-ranging raccoons ( Procyon lotor) in the US, 37 raccoons from ORV-baited areas in Pennsylvania were live-trapped and transferred to captivity to evaluate protection against rabies in animals with varying levels of existing neutralizing antibodies, expressed in international units per milliliter (IU/mL). Among the 37 raccoons at the date of capture, 24% (9/37) of raccoons were seronegative (<0.05 IU/mL), 22% (8/37) were low positive (≥0.05-0.11 IU/mL), 27% (10/37) were medium positive (>0.11-<0.5 IU/mL), and 27% (10/37) were high positive (≥0.5 IU/mL). Raccoons were held for 86-199 d between the date of capture and rabies virus challenge. At challenge, 68% (25/37) raccoons were seronegative. The overall survival rate among challenged animals was 46% (17/37). Based on the antibody titers at the time of challenge, survivorship was 24% (6/25) among seronegative animals, 100% (4/4) among low positive animals, 83% (5/6) among medium positive animals, and 100% (2/2) among high positive animals. Evidence of high-titer seroconversion after vaccination is a good surrogate indicator of rabies survival; however, survival rates of approximately 45% (15/35) were found among raccoons with detectable titers below 0.5 IU/mL. In contrast, any detectable titer at the time of challenge (>3 mo after vaccination) appeared to be a surrogate indicator of survival. Overall, we illustrated significant differences in the value of specific titers as surrogates for survival based on the timing of measurement relative to vaccination. However, survivorship was generally greater than 45% among animals with any detectable titer regardless of the timing of measurement. These findings suggest that lower titer cutoffs may represent a valid approach to measuring immunization coverage within ORV management zones, balancing both sensitivity and specificity for estimating herd immunity.

Antigenic site changes in the rabies virus glycoprotein dictates functionality and neutralizing capability against divergent lyssaviruses

Lyssavirus infection has a near 100 % case fatality rate following the onset of clinical disease, and current rabies vaccines confer protection against all reported phylogroup I lyssaviruses. However, there is little or no protection against more divergent lyssaviruses and so investigation into epitopes within the glycoprotein (G) that dictate a neutralizing response against divergent lyssaviruses is warranted. Importantly, the facilities required to work with these pathogens, including wild-type and mutated forms of different lyssaviruses, are scarcely available and, as such, this type of study is inherently difficult to perform. The relevance of proposed immunogenic antigenic sites within the lyssavirus glycoprotein was assessed by swapping sites between phylogroup-I and -II glycoproteins. Demonstrable intra- but limited inter-phylogroup cross-neutralization was observed. Pseudotype viruses (PTVs) presenting a phylogroup-I glycoprotein containing phylogroup-II antigenic sites (I, II III or IV) were neutralized by antibodies raised against phylogroup-II PTV with the site II (IIb, aa 34-42 and IIa, aa 198-200)-swapped PTVs being efficiently neutralized, whilst site IV-swapped PTV was poorly neutralized. Specific antibodies raised against PTV-containing antigenic site swaps between phylogroup-I and -II glycoproteins neutralized phylogroup-I PTVs efficiently, indicating an immunodominance of antigenic site II. Live lyssaviruses containing antigenic site-swapped glycoproteins were generated and indicated that specific residues within the lyssavirus glycoprotein dictate functionality and enable differential neutralizing antibody responses to lyssaviruses.

Rabies - epidemiology, pathogenesis, public health concerns and advances in diagnosis and control: a comprehensive review

Rabies is a zoonotic, fatal and progressive neurological infection caused by rabies virus of the genus Lyssavirus and family Rhabdoviridae. It affects all warm-blooded animals and the disease is prevalent throughout the world and endemic in many countries except in Islands like Australia and Antarctica. Over 60,000 peoples die every year due to rabies, while approximately 15 million people receive rabies post-exposure prophylaxis (PEP) annually. Bite of rabid animals and saliva of infected host are mainly responsible for transmission and wildlife like raccoons, skunks, bats and foxes are main reservoirs for rabies. The incubation period is highly variable from 2 weeks to 6 years (avg. 2-3 months). Though severe neurologic signs and fatal outcome, neuropathological lesions are relatively mild. Rabies virus exploits various mechanisms to evade the host immune responses. Being a major zoonosis, precise and rapid diagnosis is important for early treatment and effective prevention and control measures. Traditional rapid Seller's staining and histopathological methods are still in use for diagnosis of rabies. Direct immunofluoroscent test (dFAT) is gold standard test and most commonly recommended for diagnosis of rabies in fresh brain tissues of dogs by both OIE and WHO. Mouse inoculation test (MIT) and polymerase chain reaction (PCR) are superior and used for routine diagnosis. Vaccination with live attenuated or inactivated viruses, DNA and recombinant vaccines can be done in endemic areas. This review describes in detail about epidemiology, transmission, pathogenesis, advances in diagnosis, vaccination and therapeutic approaches along with appropriate prevention and control strategies.

Cost and Relative Value of Road Kill Surveys for Enhanced Rabies Surveillance in Raccoon Rabies Management

Oral rabies vaccination (ORV) requires knowledge of the spatial-temporal distribution of rabies virus variants targeted for control. Rabies-exposure based public health surveillance alone may not provide a sound basis for ORV decisions. The value and cost of road kill surveys was evaluated for the late spring–early fall 2005–2007 as a part of enhanced rabies surveillance in northern New York, where raccoon rabies is enzootic and ORV has occurred since the late 1990s. Structured surveys were conducted to collect raccoons and other meso-carnivores for rabies testing at the New York State Rabies Laboratory. Of the 209 meso-carnivore heads collected and submitted for testing, 175 were testable by direct fluorescent antibody; none was rabid. Rabies was also not reported through public health surveillance in survey zones during 2005–2007. Overall, survey costs were $37,118 (2016 USD). Salaries and benefits accounted for 61% of costs, followed by fuel (22%), vehicle depreciation (14%), and sample shipping (3%). Mean daily distance driven was 303 ± 37 km and 381 ± 28 km for total road kills and raccoons, respectively. Costs/road kill collected and submitted was $176/all species and $224/raccoon. This study provides costs for planning road kill surveys and underscores the need to continually improve enhanced rabies surveillance approaches to support ORV decision making.

Vampire bat rabies: ecology, epidemiology and control

Extensive surveillance in bat populations in response to recent emerging diseases has revealed that this group of mammals acts as a reservoir for a large range of viruses. However, the oldest known association between a zoonotic virus and a bat is that between rabies virus and the vampire bat. Vampire bats are only found in Latin America and their unique method of obtaining nutrition, blood-feeding or haematophagy, has only evolved in the New World. The adaptations that enable blood-feeding also make the vampire bat highly effective at transmitting rabies virus. Whether the virus was present in pre-Columbian America or was introduced is much disputed, however, the introduction of Old World livestock and associated landscape modification, which continues to the present day, has enabled vampire bat populations to increase. This in turn has provided the conditions for rabies re-emergence to threaten both livestock and human populations as vampire bats target large mammals. This review considers the ecology of the vampire bat that make it such an efficient vector for rabies, the current status of vampire-transmitted rabies and the future prospects for spread by this virus and its control.

Bovine rabies in Turkey: patterns of infection and implications for costs and control

The incidence of rabies in livestock is an important factor for estimating the economic impact of the disease, but obtaining reliable data is hindered by inadequate surveillance. In order to understand the contribution of livestock rabies to the overall burden of disease, the rabies incidence in cattle was investigated in detail for Turkey between 2008 and 2011. Data were compiled on cattle numbers, samples submitted for rabies diagnosis, vaccinated animals and positive rabies cases in animals for seven regions in Turkey. Rabies incidence in cattle fluctuated annually and differed between regions from 0·10 to 3·87 cases/100 000 animals. The positive influence of compensation schemes was observed. Livestock losses were conservatively estimated at around $250 000 international dollars per annum, although in areas where compensation schemes are not operating this could be an underestimate of the economic burden. Vaccination of cattle remains an option for disease prevention, although oral rabies vaccination through aerially distributed baits should be implemented to prevent the further spread of fox-mediated rabies, which could result in much greater economic costs.

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.

Rabies epidemiology, risk assessment, and pre- and post exposure vaccination

Rabies should always be considered in the differential diagnosis of a neurologic disease in a mammal with an unknown vaccination status. Public health veterinarians are available to assist in risk assessment as well as coordination of animal testing. This article discusses the pathogenesis of rabies and clinical presentation in several domestic species. Prevention, North American prevalence and distribution, exposure considerations, and post-exposure prophylaxis are also discussed. Veterinarians in private practice have an integral role in protection of people and domestic animals against rabies.

Bat and virus

Bat, the only flying mammal and count more than 20% of the extant mammals on earth, were recently identified as a natural reservoir of emerging and reemerging infectious pathogens. Astonishing amount (more than 70) and genetic diversity of viruses isolated from the bat have been identified in different populations throughout the world. Many studies focus on bat viruses that caused severe domestic and human diseases. However, many viruses were found in apparently healthy bats, suggesting that bats may have a specific immune system or antiviral activity against virus infections. Therefore, basic researches for bat immunology and virus-host interactions are important for understanding bat-derived infectious diseases.

Experimental rabies vaccines for humans

Rabies remains a global public health threat that kills more than 55,000 people per year. Rabies disproportionately affects children and, therefore, is ranked the seventh most important infectious disease due to years lost. Prevention of human rabies is accomplished by controlling rabies in domestic and wild animals, including the use of vaccination programs. The usefulness of human rabies vaccines is hampered by high cost, complicated vaccination regimens and lack of compliance, especially in areas of Africa and Asia where human rabies infections are endemic. A single-dose vaccine would greatly benefit efforts to combat this global health threat. However, a single-dose vaccine based on current inactivated vaccines does not appear feasible and other approaches are needed. Technology has advanced since modern human rabies vaccines were developed over 40 years ago. In addition, our understanding of immunological principles that influence the outcome of vaccination has increased. This article describes the current status of inactivated rabies virus vaccines and recent developments arising from the use of reverse genetics technologies designed to develop replication-deficient or single-cycle live rabies virus-based vectors for use as a single-dose rabies vaccine for humans.

Surveillance of rabies prevalence and bite protocols in captive mammals in American zoos

A national survey questionnaire was conducted in 32 zoos throughout 17 U.S. states between February and May 2008. The questionnaire consisted of six questions that evaluated rabies prevalence on zoo grounds; captive mammalian bites among zoo visitors and personnel; and the outcome of each incident. The survey was completed by zoo staff after review of their most recent bite incident reports. Rabies was documented, albeit minimally, on zoo grounds in both wild and collection animals. The information collected documented that mammalian bites occur commonly. An average of 9.1 bite incidents per zoo involving zoo visitors were reported in the last 5 yr, compared to an average of 7.5 bite incidents per zoo involving personnel within the last 5 yr. Zoo personnel had a larger variety of mammals inflicting bites of greater injury severity, with an average rating 3.83 out of 5. While victim profile and severity of the wound differed between visitor and personnel bites, the majority of bites were not reported to the local health department. Lack of reporting may be due to low rabies risk, fear of media involvement, and an unknown conclusion for the offending animal. Animals involved in reported attacks had an average quarantine of 47.5 days when the bite involved a zoo visitor versus an average quarantine of 18 days when the bite involved personnel. These results demonstrate the need for a standardized protocol following a bite incident, including cooperation with the local health department, as necessary.

Estimating the risk of rabies transmission to humans in the U.S.: a Delphi analysis

Background

In the United States, the risk of rabies transmission to humans in most situations of possible exposure is unknown. Controlled studies on rabies are clearly not possible. Thus, the limited data on risk has led to the frequent administration of rabies post-exposure prophylaxis (PEP), often in inappropriate circumstances.

Methods

We used the Delphi method to obtain an expert group consensus estimate of the risk of rabies transmission to humans in seven scenarios of potential rabies exposure. We also surveyed and discussed the merits of recommending rabies PEP for each scenario.

Results

The median risk of rabies transmission without rabies PEP for a bite exposure by a skunk, bat, cat, and dog was estimated to be 0.05, 0.001, 0.001, and 0.00001, respectively. Rabies PEP was unanimously recommended in these scenarios. However, rabies PEP was overwhelmingly not recommended for non-bite exposures (e.g. dog licking hand but unavailable for subsequent testing), estimated to have less than 1 in 1,000,000 (0.000001) risk of transmission.

Conclusions

Our results suggest that there are many common situations in which the risk of rabies transmission is so low that rabies PEP should not be recommended. These risk estimates also provide a key parameter for cost-effective models of human rabies prevention and can be used to educate health professionals about situation-specific administration of rabies PEP.

Oral rabies vaccination in north america: opportunities, complexities, and challenges

Steps to facilitate inter-jurisdictional collaboration nationally and continentally have been critical for implementing and conducting coordinated wildlife rabies management programs that rely heavily on oral rabies vaccination (ORV). Formation of a national rabies management team has been pivotal for coordinated ORV programs in the United States of America. The signing of the North American Rabies Management Plan extended a collaborative framework for coordination of surveillance, control, and research in border areas among Canada, Mexico, and the US. Advances in enhanced surveillance have facilitated sampling of greater scope and intensity near ORV zones for improved rabies management decision-making in real time. The value of enhanced surveillance as a complement to public health surveillance was best illustrated in Ohio during 2007, where 19 rabies cases were detected that were critical for the formulation of focused contingency actions for controlling rabies in this strategically key area. Diverse complexities and challenges are commonplace when applying ORV to control rabies in wild meso-carnivores. Nevertheless, intervention has resulted in notable successes, including the elimination of an arctic fox (Vulpes lagopus) rabies virus variant in most of southern Ontario, Canada, with ancillary benefits of elimination extending into Quebec and the northeastern US. Progress continues with ORV toward preventing the spread and working toward elimination of a unique variant of gray fox (Urocyon cinereoargenteus) rabies in west central Texas. Elimination of rabies in coyotes (Canis latrans) through ORV contributed to the US being declared free of canine rabies in 2007. Raccoon (Procyon lotor) rabies control continues to present the greatest challenges among meso-carnivore rabies reservoirs, yet to date intervention has prevented this variant from gaining a broad geographic foothold beyond ORV zones designed to prevent its spread from the eastern US. Progress continues toward the development and testing of new bait-vaccine combinations that increase the chance for improved delivery and performance in the diverse meso-carnivore rabies reservoir complex in the US.

Time series analysis of the impact of oral vaccination on raccoon rabies in West Virginia, 1990-2007

To assess the potential impact of oral rabies vaccination (ORV) on the occurrence of raccoon rabies in the mid-Atlantic region, temporal and seasonal trends of raccoon rabies cases reported in West Virginia from 1990 to 2007 were identified with both descriptive statistical analysis and exploratory time series analysis. Raccoon rabies cases in the non-ORV region maintain an enzootic pattern and increase over time; a bimodal seasonal pattern is observed with a large peak in April and a smaller peak in August. The results of the model indicate that the effect of the ORV intervention to control raccoon rabies was statistically significant. ORV should be attempted in other enzootic raccoon rabies areas.

Tactics and economics of wildlife oral rabies vaccination, Canada and the United States

Economic assessments and modeling studies suggest that these programs yield cost savings and public health benefits.

Progressive elimination of rabies in wildlife has been a general strategy in Canada and the United States; common campaign tactics are trap–vaccinate–release (TVR), point infection control (PIC), and oral rabies vaccination (ORV). TVR and PIC are labor intensive and the most expensive tactics per unit area (≈$616/km² [in 2008 Can$, converted from the reported $450/km² in 1991 Can$] and ≈$612/km² [$500/km² in 1999 Can$], respectively), but these tactics have proven crucial to elimination of raccoon rabies in Canada and to maintenance of ORV zones for preventing the spread of raccoon rabies in the United States. Economic assessments have shown that during rabies epizootics, costs of human postexposure prophylaxis, pet vaccination, public health, and animal control spike. Modeling studies, involving diverse assumptions, have shown that ORV programs can be cost-efficient and yield benefit:cost ratios >1.0.

Replication-deficient rabies virus-based vaccines are safe and immunogenic in mice and nonhuman primates

Although current postexposure prophylaxis rabies virus (RV) vaccines are effective, approximately 40,000-70,000 rabies-related deaths are reported annually worldwide. The development of effective formulations requiring only 1-2 applications would significantly reduce mortality. We assessed in mice and nonhuman primates the efficacy of replication-deficient RV vaccine vectors that lack either the matrix (M) or phosphoprotein (P) gene. A single dose of M gene-deficient RV induced a more rapid and efficient anti-RV response than did P gene-deficient RV immunization. Furthermore, the M gene-deleted RV vaccine induced 4-fold higher virus-neutralizing antibody (VNA) levels in rhesus macaques than did a commercial vaccine within 10 days after inoculation, and at 180 days after immunization rhesus macaques remained healthy and had higher-avidity antibodies, higher VNA titers, and a more potent antibody response typical of a type 1 T helper response than did animals immunized with a commercial vaccine. The data presented in this article suggest that the M gene-deleted RV vaccine is safe and effective and holds the potential of replacing current pre- and postexposure RV vaccines.

Knowledge and perceptions of dog-associated zoonoses: Brazos County, Texas, USA

In order to assess the knowledge and perceptions of dog-associated zoonoses in Brazos County, Texas, random digit dialing was used to select 922 households for participation in a cross-sectional telephone survey. The interviews were completed during June 2008 and yielded a response rate of 55% (922/1691). Fifty-six percent of the respondents who completed the questionnaire owned dogs. Eighty-six percent of the respondents indicated they would report being bitten by a dog that they did not own. Five factors were shown to be significantly associated with such reporting. Those respondents who believed that rabies could be transmitted by bats were 5.5 times more likely (95% CI: 1.6, 18.6) to report a dog bite compared to people who did not hold this belief. Respondents who would seek emergency treatment if they believed they had been exposed to rabies were 3.1 times more likely to report a bite (95% CI: 1.8, 5.4). Those who were over 60 years of age were 2.3 times more likely (95% CI: 1.2, 4.4) to report being bitten when compared to respondents who were under the age of 60. Living inside the city limits also increased the chance that the respondent would report being bitten by a dog (OR 2.3, 95% CI: 1.4, 3.9). Females were 2.3 times more likely (95% CI: 1.3, 3.7) to report being bitten than their male counterparts. Dog ownership did not have a significant impact on reporting. Only 85% of respondents stated that they would seek emergency treatment if they believed that they may have been exposed to rabies. In addition, only 59% of respondents were aware that exposure to rabies without treatment could lead to death. While 98% of respondents had heard of rabies and knew that it was possible to get it from a dog, only 54% of respondents knew that worms could be transmitted from dogs to people. This study demonstrated that many people surveyed lacked knowledge about dog-associated zoonotic diseases, which could seriously impact their health and the health of their families. It is important to find a method of getting information out to the public in order to correct this deficiency.