Rabies postexposure prophylaxis, New York, 1995-2000

Analysis of qualification for post-exposure prophylaxis against rabies in children in Poland

BACKGROUND

Rabies is a fatal disease caused by the rabies virus, usually transmitted by a bite by an infected animal. Because there is no effective treatment, prophylaxis is crucial. The aim of the study was to analyse the circumstances of exposure, characterise the animals that were a potential source of infection and evaluate the frequency of post-exposure prophylaxis in children.

METHODS

This was a retrospective analysis of the medical records of 494 children who had been bitten, scratched or salivated on by an animal and were seen consecutively between 2015 and 2019 in the Department of Paediatric Infectious Diseases, Medical University of Warsaw.

RESULTS

The study group was children aged 10 months to 17 years 11 months. The animals most commonly involved were dogs (347/494, 70.24%), cats (81/494 (16.40%) and squirrels (10/494, 2.02%). The contact was mainly with tame but unfamiliar animals (359/494, 72.67%, p < 0.001). The most common type of exposure was a bite (457/494, 92.51%). Surgical wound care was required most often after exposure in a town (64/90, 71.11%). A total of 412 children (80.83%) received post-exposure vaccination, including 333/412 using the Essen regimen. In 13/412 cases, the vaccination schedule (3.16%) was not completed because of an absence of signs of disease during veterinary observation of the animal. Anti-rabies immunoglobulin was administered to 13/412 (3.16%).

CONCLUSION

Most children who are referred after being bitten by an animal require post-exposure prophylaxis. Children are usually bitten by tame dogs with which they are unfamiliar, mostly on the hand. Surgical wound care is needed more often for urban patients than others.

Safety and efficacy of rabies immunoglobulin in pediatric patients with suspected exposure

Rabies is a deadly viral zoonosis with global disease burden. Following exposure to a rabid animal, post-exposure prophylaxis (PEP) is the standard of care for unvaccinated persons. Despite the large proportion of pediatric cases, limited safety and efficacy data exist for use in pediatric patients. We report the safety, efficacy, and immunogenicity of a phase 4, prospective, 2-center, open-label, single-arm clinical trial evaluating human rabies immunoglobulin (HRIG150; KEDRAB 150 IU/mL) as part of PEP in patients (aged <17) with suspected or confirmed rabies exposure, where PEP was indicated. Thirty participants received 20 IU/kg HRIG150 infiltrated into the detectable wound site(s), with any remainder injected intramuscularly, concomitantly with the first of a 4-dose series (days 0, 3, 7, and 14) of rabies vaccine. Rabies virus neutralizing antibody (RVNA) titers and tolerability were assessed on day 14 following administration. Participant safety was monitored for 84 days. No serious adverse events, rabies infections, or deaths were recorded. Twenty-one participants (70.0%) experienced a total of 57 treatment-emergent adverse events (TEAEs) within 14 days following administration. Twelve participants (40.0%) experienced a total of 13 adverse events deemed treatment related. All TEAEs were mild in severity. On day 14, 28 participants (93.3%) had RVNA levels of ≥0.5 IU/mL (mean±standard deviation: 18.89 ± 31.61). These results demonstrate that HRIG150 is well tolerated and effective in pediatric patients as a component of PEP. To the authors' knowledge, this study is the first to establish pediatric safety and efficacy of HRIG in the US.

Atendimentos antirrábicos humanos pós-exposição: tendência temporal de sua prevalência no Ceará, de 2007 a 2015

Resumo Introdução A principal recomendação para o controle da raiva em humanos é a vacinação profilática. Objetivo Considerando-se a endemicidade da raiva no Brasil e o direcionamento das ações de controle, buscou-se caracterizar a tendência temporal dos atendimentos antirrábicos humanos pós-exposição no Ceará, de 2007 a 2015. Método O estudo é ecológico de tendência temporal e analítico. Os dados das fichas de atendimento antirrábico foram organizados em planilhas e calculados os coeficientes anuais de prevalência. Resultados Houve 231.694 atendimentos antirrábicos, com coeficientes de prevalência crescentes de 2007 a 2011 (35,09 por 10.000 habitantes; APC=13,5; p<0,001) e ápice em 2015 (40,35 por 10.000 habitantes; APC=5,5; p=0,005). Houve um aumento na faixa etária de 20 a 59 anos (APC=14,0; p<0,001), e residentes da zona urbana (APC=7,0; p<0,001). A espécie canina teve tendência crescente de 2007 a 2011 (APC=14,3; p<0,001). Das notificações, 95,8% apresentaram condutas inadequadas, com crescimento nos coeficientes de prevalência de 2007 a 2011 (APC=13,6; p<0,001). Conclusão As condutas profiláticas inadequadas aconteceram mais de 2007 a 2011. A análise temporal, com tendência crescente no período analisado, deve ser utilizada como componente contínuo das ações de vigilância da raiva no Ceará, para assistência adequada e segura aos pacientes vítimas de agressão animal.

Assessment of the immunogenicity of rabies vaccine preserved by vaporization and delivered to the duodenal mucosa of gray foxes (Urocyon cinereoargenteus)

OBJECTIVE To assess the immunogenicity of thermostable live-attenuated rabies virus (RABV) preserved by vaporization (PBV) and delivered to the duodenal mucosa of a wildlife species targeted for an oral vaccination program. ANIMALS 8 gray foxes (Urocyon cinereoargenteus). PROCEDURES Endoscopy was used to place RABV PBV (n = 3 foxes), alginate-encapsulated RABV PBV (3 foxes), or nonpreserved RABV (2 foxes) vaccine into the duodenum of foxes. Blood samples were collected weekly to monitor the immune response. Saliva samples were collected weekly and tested for virus shedding by use of a conventional reverse-transcriptase PCR assay. Foxes were euthanized 28 days after vaccine administration, and relevant tissues were collected and tested for presence of RABV. RESULTS 2 of 3 foxes that received RABV PBV and 1 of 2 foxes that received nonpreserved RABV seroconverted by day 28. None of the 3 foxes receiving alginate-encapsulated RABV PBV seroconverted. No RABV RNA was detected in saliva at any of the time points, and RABV antigen or RNA was not detected in any of the tissues obtained on day 28. None of the foxes displayed any clinical signs of rabies. CONCLUSIONS AND CLINICAL RELEVANCE Results for this study indicated that a live-attenuated RABV vaccine delivered to the duodenal mucosa can induce an immune response in gray foxes. A safe, potent, thermostable RABV vaccine that could be delivered orally to wildlife or domestic animals would enhance current rabies control and prevention efforts.

Incidence of human rabies exposure and associated factors at the Gondar Health Center, Ethiopia: a three-year retrospective study

BACKGROUND

Rabies is one of the oldest known and most feared human diseases. Epidemiological studies provide basic information about the burden of the disease and underline the importance of prevention and control interventions. However, there have been limited studies conducted regarding the incidence of rabies and associated factors in Ethiopia, in general, and in this study area, in particular. Therefore, the aim of this study was to assess the incidence of human rabies exposure and associated factors at the Gondar Health Center, Ethiopia.

METHODS

A retrospective cross-sectional study was conducted at the Gondar Health Center where post-exposure prophylaxis (PEP) for rabies was available for the whole population in the North Gondar Zone catchment area. Data of human rabies exposure cases between 2011 and 2013 were collected from the rabies PEP registration book using data abstraction sheets. The data was entered and analyzed using SPSS version 16 statistical software.

RESULT

A total of 261 cases of human rabies exposure were reported to the Gondar Health Center from 2011 to 2013. The sex and age specific distribution showed that the majority of these cases were among males (142/226, 62.8%) and children under 15 years of age (87/226, 38.5%). A predominant number of cases were observed in individuals from rural areas (161/220, 73.2%), and during fall and winter seasons (67/222, 30.18%). A significant number of people exposed to rabies (23.2%) came to the health center for PEP two or more weeks after the injury. The incidence of human rabies exposure cases was 4.6, 2.61, and 1.27 per 100, 000 population in 2011, 2012, and 2013, respectively. Being male and living in an urban setting were found to be risk factors for human rabies exposure in 2011.

CONCLUSION

A significant number of human rabies exposure cases were reported to the Gondar Health Center. Being male and living in an urban setting were found to be associated with rabies exposure. A community-based follow-up study is recommended to more accurately estimate the incidence of human rabies exposure.

Reported rabies pre-exposure immunization of students at US Colleges of Veterinary Medicine

In 2008, the US experienced a disruption in human rabies vaccine supplies, leading public health authorities to prioritize vaccine release for post-exposure prophylaxis (PEP) and limit vaccine supplies for pre-exposure prophylaxis (PreEP) in high-risk groups. In 2008, the Association of American Veterinary Medical Colleges (AAVMC) surveyed its member institutions on rabies vaccination policies and practices. Senior administrators at Colleges of Veterinary Medicine (CVMs) and departments of veterinary science and comparative medicine were asked to identify the person most knowledgeable about their institution's student rabies vaccination program. Respondents were asked to describe their policies and procedures for administering PreEP to veterinary medical students and staff and to estimate the annual demand for student and staff PreEP vaccine. Twenty-one CVMs responded. Twenty (95%) reported requiring PreEP of veterinary medical students and 16 (80%) of those 20 required vaccination upon matriculation. An estimated 7,309 doses of vaccine were required for PreEP of an estimated 2,436 first-year US veterinary medical students. Seventy-two percent of respondents administered PreEP in August, September, and October, coinciding with the highest public demand for PEP. CVMs should consider altering the timing of rabies vaccine administration to veterinary medical students and staff to other months, thereby helping to ensure that PEP rabies vaccine will be available to people with validated rabies exposures and to ensure that supplies will be available for PreEP of students and staff. AAVMC may wish to identify and support a point of coordination to facilitate the purchase and distribution of human rabies vaccine among its US member CVMs.

Rabies: still a uniformly fatal disease? Historical occurrence, epidemiological trends, and paradigm shifts

Rabies has the highest case fatality of any infectious disease. Pathobiological and clinical insights have questioned the assertion that death is inevitable after onset of acute encephalomyelitis. Relying upon national laboratory-based surveillance, we reviewed records of human rabies acquired in the United States during 1960-2009. Changes in the epidemiology of human rabies were notable, due to improved animal management, safer and more efficacious biologics, and revisions in prevention guidelines. Historically, domestic animals were the most important source of infection. Since the 1990s, more human cases were associated with rabid bats. Prior to 1980, postexposure prophylaxis failures were reported. After development of modern rabies immune globulin and vaccines, none occurred. Of 75 human cases identified, only four patients survived. Rabies remains an extremely high consequence zoonosis, but the disease is not uniformly fatal, per se. Rabies is essentially preventable when primary exposures are averted, or appropriate prophylaxis occurs before illness.

Community survey after rabies outbreaks, Flagstaff, Arizona, USA

Educational outreach should inform the public about dangers of translocation of wild animals and general aspects of rabies.

Flagstaff, Arizona, USA, experienced notable outbreaks of rabies caused by a bat rabies virus variant in carnivore species in 2001, 2004, 2005, 2008, and 2009. The most recent epizootic involved transmission among skunk and fox populations and human exposures. Multiple, wide-ranging control efforts and health communications outreach were instituted in 2009, including a household survey given to community members. Although the Flagstaff community is knowledgeable about rabies and the ongoing outbreaks in general, gaps in knowledge about routes of exposure and potential hosts remain. Future educational efforts should include messages on the dangers of animal translocation and a focus on veterinarians and physicians as valuable sources for outreach. These results will be useful to communities experiencing rabies outbreaks as well as those at current risk.

Effectiveness of breed-specific legislation in decreasing the incidence of dog-bite injury hospitalisations in people in the Canadian province of Manitoba

Background

The city of Winnipeg was the first among several jurisdictions in Manitoba, Canada, to introduce breed specific legislation (BSL) by banning pit-bull type dogs in 1990. The objective of the present work was to study the effectiveness of BSL in Manitoba.

Methods

Temporal differences in incidence of dog-bite injury hospitalisations (DBIH) within and across Manitoba jurisdictions with and without BSL were compared. Incidence was calculated as the number of unique cases of DBIH divided by the total person-years at risk and expressed as the number per 100 000 person-years. Year of implementation determined the pre-BSL and post-BSL period for jurisdictions with BSL; for jurisdictions without BSL to date, the entire study period (1984–2006) was considered as the preimplementation period. The annual number of DBIH, adjusted for total population at risk, was modelled in a negative binomial regression analysis with repeated measures. Year, jurisdiction and BSL implementation were independent variables. An interaction term between jurisdiction and BSL was introduced.

Results

A total of 16 urban and rural jurisdictions with pit-bull bans were identified. At the provincial level, there was a significant reduction in DBIH rates from the pre-BSL to post-BSL period (3.47 (95% CI 3.17 to 3.77) per 100 000 person-years to 2.84 (95% CI 2.53 to 3.15); p=0.005). In regression restricted to two urban jurisdictions, DBIH rate in Winnipeg relative to Brandon (a city without BSL) was significantly (p<0.001) lower after BSL (rate ratio (RR)=1.10 in people of all ages and 0.92 in those aged <20 years) than before (RR=1.29 and 1.28, respectively).

Conclusions

BSL may have resulted in a reduction of DBIH in Winnipeg, and appeared more effective in protecting those aged <20 years.

Human and animal rabies prevention and control cost in Bhutan, 2001-2008: the cost-benefit of dog rabies elimination

The objective of this study was to estimate the cost of various interventions and to quantify the economic impacts of rabies in Bhutan. Cost-benefit of dog rabies elimination versus human post exposure treatment cost was also assessed. The average direct medical cost of human post-exposure treatment (using rabies vaccine only) was estimated to be Nu. 1615 (US$ 35.65) per 5-dose Essen regimen per patient. The cost would increase to Nu. 2497 (US$ 55.13) and Nu. 19,633 (US$ 433.41) per patient when one dose of either equine rabies immunoglobulin (ERIG) or human rabies immunoglobulin (HRIG) is administered, respectively. The societal cost (direct medical and indirect patient expenses) per patient was estimated to be Nu. 2019 (US$ 45), Nu. 2901 (US$ 64) and Nu. 20,037 (US$ 442) using vaccine only, vaccine with ERIG and vaccine with HRIG, respectively. The average cost per dog vaccination and sterilization were estimated to be Nu. 75 (US$ 1.66) and Nu. 288 (US$ 6.36), respectively. The total direct cost of rabies and various interventions between 2001 and 2008 was estimated to be Nu. 46.95 million (US$ 1.03 million). The direct cost for intensified human PET was estimated to be Nu. 5.85 million (US$ 0.11 million) per year with a cumulated estimated costs of Nu. 35.10 million (US$ 0.70 million) while the cost of mass dog vaccination with at least 70% coverage is estimated to be approximately Nu. 10.31 million (US$ 0.21 million) at the end of 6 years. The combined cost of mass dog vaccination and human PET was estimated to be greater than the cost of human PET alone during the first 2 years of the campaign, and then would be lower than human PET cost alone after the 5th year of the campaign. The total cumulated cost of the combined strategy was estimated to be Nu. 34.14 million (US$ 0.73 million) and would be lower than the cumulated cost of human PET alone (Nu. 35.10 million, US$ 0.77 million) at the end of 6 years. Rabies represents a substantial economic impact to the Bhutanese society. Well-planned and implemented mass dog vaccination would result in elimination of rabies reservoirs in the domestic dog population and would eliminate human rabies cases. It would also reduce the recurrent expenditure on human post-exposure treatment.

[Epidemiologic profile of human anti-rabies treatment in Porto Alegre, RS, brazil]

Animal bites are injuries that carry the risk of rabies transmission, a disease with a 100% mortality rate. The purpose of this study was to determine the epidemiologic profiles of post exposure human anti-rabies treatments and to analyze whether prescriptions were appropriate. This cross-sectional study collected data from the forms of the Brazilian Notification System (Sistema Nacional Agravos de Notificação - SINAN), which were filled out by the professionals responsible for treatment in healthcare services in the second semester of 2006. Of the 2,223 cases identified, 50.3% of the individuals were male, the age group with the greatest number of cases was 20 to 59 years (47.6%); the type of injury responsible for the largest number of medical consultations was animal bite (87.4%), and 35.3% of the injuries were in the lower extremities. Dogs were the animals that caused the most injuries (91.7%). The analysis of type of treatment showed that vaccination was prescribed for 78.1% of the individuals, and anti-rabies serum, for 6.4%. Of the all treatments, 96.2% were classified as correctly prescribed. Although treatments were classified as necessary, the option of keeping animals that cause aggressions under observation should be considered so that the number of treatments administered can be reduced.

Human rabies post exposure prophylaxis in Bhutan, 2005-2008: trends and risk factors

The aim of this study was to understand the use and distribution of human rabies post exposure prophylaxis (PEP) vaccine in Bhutan and to identify risk factors for receiving an incomplete course of the vaccine. We analyzed post exposure treatment records from 28 medical hospitals from 2005 to 2008. Males (59%) accounted for significantly more PEP events than females (41%) across all age groups (P<0.001). Children - particularly 5-9 years of age - received more rabies PEP than other age groups. Animal bite and non-bite accounted for 27% (n=2239) and 16% (n=1303) of rabies PEP, respectively, whilst 57% (n=4773) of the PEP events had no recorded information about the reasons for post exposure treatment. Post exposure treatment was provided throughout the year with a higher number during the winter and spring months. The number of PEP events significantly (P<0.001) increased between 2005 and 2008, from <1000 to >2800 events, respectively. Significantly (P<0.001) more PEP events were reported from the southern parts of Bhutan that are endemic for rabies or those areas in eastern Bhutan that have reported rabies outbreaks than other parts of Bhutan. Forty percent (n=3360) of the patients received an incomplete course of vaccine (<5-doses of vaccine intramuscular). Results suggest that patients with animal bite injury were less likely to receive an incomplete vaccine course than non-bite recipients, and patients presented to hospitals in rabies endemic or outbreak areas were less likely to receive an incomplete course than in non-rabies areas or rabies free areas. Similarly, patients presenting to hospitals for PEP during spring and summers months were less likely to receive an incomplete vaccine course than those during other seasons. Public education campaigns need to be conducted in Bhutan to reduce dog bite incidents and also to prevent mass exposures to rabies. A thorough assessment of each individual case based on the WHO guidelines would reduce unnecessary PEP (and therefore costs) in Bhutan.

[Abandon reasons of post-exposure human anti-rabies treatment in Porto Alegre (RS, Brazil)]

In Brazil, rabies is an endemic disease with a fatality rate of 100%. The number of cases has decreased, but the number of cases for treatment after exposure and treatment dropout is still high. This study investigated the causes of anti-rabies treatment abandon, after exposure, in Porto Alegre (RS, Brazil), from July to December 2006. A case series was designed. Two hundred and eighty abandon cases were selected through randomized systematic sampling, out of 962 registered in Sinan. Data was collected in people's homes through interviews, by means of a questionnaire. According to the interviewees, 66.4% concluded the prescribed number of vaccines. This information was not registered in Sinan. Among the subjects confirmed of abandoning the treatment (94/280), 24.5% reported that they thought it was not necessary to complete the treatment, while 13.8% felt that they did not receive clear guidelines about what to do. Health services attempted to contact absents in only 19.2% of the cases. Data entered in Sinan present failures. These occurred because patients started treatment at one health service and continued in a different one. As a consequence, information about the conclusion of the treatment was not entered into the system.

Terrestrial rabies and human postexposure prophylaxis, New York, USA

During 1993–2002, cats accounted for 2.7% of rabid terrestrial animals in New York but for one third of human exposure incidents and treatments. Nonbite exposures and animals of undetermined rabies status accounted for 54% and 56%, respectively, of persons receiving rabies treatments.

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.

Rabies surveillance in the United States during 2008

During 2008, 49 states and Puerto Rico reported 6,841 cases of rabies in animals and 2 cases in humans to the CDC, representing a 3.1% decrease from the 7,060 cases in animals and 1 case in a human reported in 2007. Approximately 93% of the cases were in wildlife, and 7% were in domestic animals. Relative contributions by the major animal groups were as follows: 2,389 (34.9%) raccoons, 1,806 (26.4%) bats, 1,589 (23.2%) skunks, 454 (6.6%) foxes, 294 (4.3%) cats, 75 (1.1%) dogs, and 59 (0.9%) cattle. Compared with numbers of cases reported in 2007, numbers of cases reported in 2008 increased among cats, cattle, and skunks and decreased among dogs, raccoons, bats, and foxes. Numbers of rabid raccoons reported during 2008 decreased in 11 of the 20 eastern states where raccoon rabies was enzootic; overall number of rabid raccoons reported decreased by 8.6% during 2008, compared with 2007. On a national level, the number of rabies cases involving skunks increased by 7.7% during 2008, compared with the number reported in 2007; this was the first increase in the number of reported rabid skunks since 2006. The total number of cases of rabies reported nationally in foxes decreased 1.7% in 2008, compared with 2007. The 1,806 cases of rabies reported in bats represented a 6.7% decrease, compared with the number reported in 2007. One case of rabies in a dog imported from Iraq was reported at a quarantine station in New Jersey during 2008. Follow-up of potentially exposed animals in the same shipment did not reveal any secondary transmission. The United States remained free from dog-to-dog transmission of canine rabies virus variants. Total number of rabid dogs reported decreased 19.4% in 2008, compared with 2007. Two human rabies cases were reported from California and Missouri during 2008. The California case involved a recent immigrant from Mexico and was attributed to a newly identified rabies virus variant most likely associated with Mexican free-tailed bats. The case in Missouri was attributed to a rabies virus variant associated with eastern pipistrelle and silver-haired bats.

Use of rabies postexposure prophylaxis supplied by the Alaska Section of Epidemiology, Alaska, 2002-2007

OBJECTIVE

The aim of this study was to summarize the Alaska experience in centralizing distribution of rabies postexposure prophylaxis (PEP).

METHODS

Data were collected from standard treatment sheets used to track doses and notes related to the exposure investigations.

RESULTS

From 2002 to 2007, the annual PEP usage rate was 2.2 per 100,000. Dogs were involved in 79% (68/86) of exposures. More than 50% (49/87) of people were exposed to a confirmed rabid animal; 31 (63%) of those people experienced nonbite exposures. Conversely, of the remaining 38 people exposed to an animal for which rabies status could not be confirmed, 35 (92%) sustained a bite or puncture. Direct and indirect costs averaged more than $3000 per person.

CONCLUSIONS

The Alaska PEP usage rate was lower and the proportion of people exposed to confirmed rabid animals was higher when compared with other states. Alaska public health personnel invested significant time to ensure that PEP was only given when indicated. Without this gatekeeper approach, PEP would likely be administered at a much higher rate because medical facility staff lacks the time or ability to investigate animal exposures to rule out rabies. In Alaska, centralizing rabies PEP not only serves the patient's best interest, but it also makes efficient use of a potentially scarce product and supports rabies surveillance efforts by guaranteeing animals for testing. Such a program might not be feasible for a more populous state or jurisdiction, or areas with different rabies epizootiology; however, that may change if the supply of rabies biologics changes in the future.

Rabies postexposure prophylaxis, Marseille, France, 1994-2005

The administration of human rabies postexposure prophylaxis near Marseille (southern France) has changed since the eradication of terrestrial mammal rabies in 2001. Most injuries were associated with indigenous dogs; rabies vaccine was overprescribed. We suggest that the World Health Organization guidelines be adapted for countries free of terrestrial mammal rabies.

Travel vaccination for rabies

Rabies is a widely distributed zoonotic disease of major public-health importance. While canine rabies has been controlled throughout most of the developed world, it remains a significant burden in developing countries, particularly in Africa and Asia. Owing to the effectiveness of local rabies control in industrialized countries, the lack of familiarity with rabies may place certain travelers to countries with a higher prevalence of rabies at higher risk for potential contact with rabid animals, requiring rabies postexposure prophylaxis. Where necessary, some travelers may need to consider rabies pre-exposure vaccination, depending on planned activities and duration of travel within a given country. Education regarding behavior around unfamiliar animals and general familiarity with local rabies epidemiology is often sufficient to reduce a person's risk of exposure. Travelers to countries where rabies is prevalent should balance the cost and inconvenience of immunization to the benefits of rabies pre-exposure vaccination.

Cost effectiveness of rabies post exposure prophylaxis in the United States

There is growing concern in the United States about the excessive use of rabies post exposure prophylaxis (PEP) treatment. In this paper we have estimated the cost effectiveness of rabies PEP treatment under various scenarios of rabies transmission. When the risk of a patient getting rabies is deemed greater than 0.7%, then giving PEP will be cost saving (societal perspective). For lower risks of transmission, cost effectiveness estimates ranged from approximately $500,000 per life saved to $billions. The uncertainty caused by the wide range of cost effectiveness can only be resolved through analysis of data describing rabies transmission risk in a variety of scenarios.

Rabies surveillance in the United States during 2006

During 2006, 49 states and Puerto Rico reported 6,940 cases of rabies in animals and 3 cases in humans to the CDC, representing an 8.2% increase from the 6,417 cases in animals and 1 case in a human reported in 2005. Approximately 92% of the cases were in wildlife, and 8% were in domestic animals. Relative contributions by the major animal groups were as follows: 2,615 raccoons (37.7%), 1,692 bats (24.4%), 1,494 skunks (21.5%), 427 foxes (6.2%), 318 cats (4.6%), 82 cattle (1.2%), and 79 dogs (1.1%). Compared with numbers of reported cases in 2005, cases in 2006 increased among all groups except cattle. Increases in numbers of rabid raccoons during 2006 were reported by 11 of the 20 eastern states where raccoon rabies was enzootic, and reported cases increased by 3.2% overall, compared with 2005. On a national level, the number of rabies cases in skunks during 2006 increased by 6.1% from the number reported in 2005. Once again, Texas reported the greatest number (n = 351) of rabid skunks and the greatest overall state total of animal rabies cases (889). No cases of rabies associated with the dog/coyote rabies virus variant were reported. The last identified case of this canine rabies virus variant was identified in March 2004, along the US/Mexico border. With 2006 marking the second year of no apparent transmission of the dog/coyote variant, these findings from surveillance data support the contention that the canine rabies virus variant is no longer in circulation in the United States. Total number of cases of rabies reported nationally in foxes increased 13.6%, compared with 2005. Increases in the number of reported rabid foxes were attributable to greater numbers of foxes reported with the Arctic fox rabies virus variant in Alaska, the Texas gray fox rabies virus variant in Texas, and the raccoon rabies virus variant in Virginia. The 1,692 cases of rabies reported in bats represented a 14.5% increase, compared with numbers reported in 2005, making bats the second most reported rabid animal behind raccoons. Cases of rabies in cats, dogs, horses and mules, and sheep and goats increased 18.2%, 3.9%, 12.8%, and 22.2%, respectively, whereas cases reported in cattle decreased 11.8%. In Puerto Rico, reported cases of rabies in mongooses increased 9.2%, and rabies in domestic animals, presumably attributable to spillover infection from mongooses, increased 20%. Three cases of human rabies were reported from Texas, Indiana, and California during 2006. The cases in Indiana and Texas were attributed to bat rabies virus variants, whereas the case in California was attributed to an exposure to a dog in the Philippines.

Rabies surveillance in the United States during 2005

During 2005, 49 states and Puerto Rico reported 6,417 cases of rabies in nonhuman animals and 1 case in a human being to the CDC, representing a 6.2% decrease from the 6,836 cases in nonhuman animals and 8 cases in human beings reported in 2004. Approximately 92% of the cases were in wildlife, and 8% were in domestic animals. Relative contributions by the major animal groups were as follows: 2,534 raccoons (39.5%), 1,478 skunks (23%), 1,408 bats (21.9%), 376 foxes (5.9%), 269 cats (4.2%), 93 cattle (1.5%), and 76 dogs (1.2%). Compared with numbers of reported cases in 2004, cases in 2005 decreased among all groups, except bats, horses, and other wild animals. Decreases in numbers of rabid raccoons during 2005 were reported by 10 of the 20 eastern states in which raccoon rabies was enzootic and decreased overall by 1.2%, compared with 2004. On a national level, the number of rabies cases in skunks during 2005 decreased 20.4% from the number reported in 2004. Once again, Texas reported the greatest number (n = 392) of rabid skunks and the greatest overall state total of rabies cases (741). Texas reported no cases of rabies associated with the dog/coyote rabies virus variant and only 8 cases associated with the Texas gray fox rabies virus variant (compared with 22 cases in 2004). The total number of cases of rabies reported nationally in foxes decreased 3.3%, compared with those reported in 2004. The 1,408 cases of rabies reported in bats represented a 3.5% increase over numbers reported in 2005. Cases of rabies in cats, dogs, cattle, and sheep and goats decreased 4.3%, 19.2%, 19.1%, and 10%, respectively, whereas cases reported in horses and mules increased 9.3%. In Puerto Rico, reported cases of rabies in mongooses increased 29.8%, and rabies in domestic animals decreased 37.5%. One case of human rabies was reported from Mississippi during 2005. This case was submitted by the state to the CDC's unexplained deaths project and diagnosed as rabies retrospectively.