Time to look at rabies with a One Health lens

In the United States, bats account for the highest rabies exposure rates. According to the CDC, rabies virus most often associated with human rabies cases in the United States is the silver-haired bat, above. Photo: Bigstock/Jay Ondreicka On September 28, 2024, we celebrated the 18th annual World Rabies Day. Rabies, a deadly virus that gave us the likes of Cujo, may have helped in the development of the vampire legend1, and until recently (and generally) still is universally fatal without timely intervention, is the quintessential zoonotic disease, a true One Health issue. Though some mammals are more susceptible than others and more likely to be exposed, it infects land and marine mammals alike. A recent outbreak in seals located in Cape Town, South Africa, shows how far-reaching the disease can be.2 Understanding how disease transmission occurs, how signs manifest and ensuring you keep it on your differential list in the face of neurological and behavioral changes can help protect you, your staff, and your clients and preserve the human-animal bond. Examining rabies within the One Health framework The Cape Town rabies outbreak in Arctocephalus pusillus (seals) shows the need for cooperation among various professionals. It exemplifies a One Health approach from scientists and researchers attempting to determine the means of transmission to veterinarians and wildlife professionals to aid in the management and prevention of disease, provide humane euthanasia and necessary care, and ensure the safety of those around them. Finally, human health plays a role in those exposed to or harmed by possibly infected animals. Education is paramount for veterinarians and lay individuals alike. Currently, viral sequencing is ongoing and may help to shed light on the possible source of infection. Understanding rabies According to the Centers for Disease Control and Prevention’s (CDC) National Rabies Surveillance System, which tracks human and animal rabies in the U.S., less than 10 humans die from rabies annually, thanks in great part to the successful canine rabies vaccination program in this country and the eradication of domestic rabies in dogs. However, wildlife rabies still poses a risk, with only 25 percent of the U.S. unlikely to be exposed. Fox, skunks, raccoons, and bats remain a threat, though the variant prevalence varies throughout the country.3 In animals, the CDC notes annual reports show that more than 4,000 cases are positive for those tested, with over 90 percent of cases found in the same species mentioned above.3 Eradicating canine rabies from the U.S. is considered one of Public Health’s most significant endeavors. Success was achieved through cooperative efforts, now recognized as One Health means, including:3 Surveillance and tracking systems for animal and human rabies cases Vaccination programs in domestic dogs and cats Animal control programs, including leash laws Ability to provide a means of prevention of the development of disease if exposed through the use of post-exposure prophylaxis (PEP) World Rabies Day started in 2007 to raise awareness of the condition and educate people on ways to protect their pets and themselves. Globally, the public health community hopes to eliminate canine rabies-induced deaths in people by 2030. To do this, vaccination campaigns are paramount. Further, since the disease knows no boundaries and is found globally except in Antarctica, it necessitates collaboration on all fronts, a One Health approach. Outside of the U.S., most rabies cases in people result from canine exposure and the canine variant, while in the U.S., bats account for the highest exposure rates.4 Rabies’ clinical picture Ensure familiarity for you and your staff with signs of clinical rabies. It should be on your differential list for any patient exhibiting neurological signs, though usually very low on most lists. Clinical signs of rabies may include:5,6 Lethargy Aberrant behavior (aggression withdrawal or recumbency, depending on the stage of rabies) Fever Hyporexia or anorexia Weakness Ataxia Self-mutilation Paralysis Intense phobia of water (more common in people than animals) Rapid loss of cranial nerve function Rapid loss of cerebral function and change in mental status Dysphagia Ptyalism Seizures Abnormal vocalizations Death A vet’s role Practicing clinical veterinarians remain a crucial player in the prevention of rabies in the U.S. By educating clients about the disease, how it is transmitted, why vaccination is paramount, the overall safety of the vaccination, the recommended vaccination schedule, potentially catastrophic effects if vaccination lapses, and alternative disease transmission prevention methods, we fulfill our obligation to safeguard our patients and their human companions. With increasing vaccine hesitancy in this post-COVID era, we must ensure owners understand: The legal requirements for vaccination in their residing area The reason behind this legal requirement – to protect the health and safety of the public (animals and people alike) To provide a means of proof of vaccination (tags and certificates) The frequency of administration (dictated by the vaccine manufacturer and jurisdiction in which we practice; either one or three years) If an unvaccinated or unknown vaccine-status animal bites their pet, the requirements for quarantine and duration if they are up-to-date on vaccination vs. if they are not The reason for asking if an animal being euthanized has recently bitten someone and the potentially fatal disease that individual may face The procedure necessary to determine if an animal is rabid (often knowing an animal needs to be euthanized and the head removed for diagnosis appalls owners but may provide the impetus to vaccinate in the face of hesitancy) If their pet were to bite a person and is vaccinated, and what may occur if they are unvaccinated. Additionally, what may be necessary/recommended by the public health officials in the area Rabies vaccination titers: Yay or nay? Veterinarians and veterinary staff fall into one of the at-risk categories for rabies; thus, pre-exposure prophylaxis via vaccination (PrEP) is recommended. However, as of May 2022, the CDC overhauled its vaccination and titer monitoring recommendations. The CDC refined its recommendations because of the rising costs of PrEP and every two-year titer testing, often not covered by healthcare insurance, a lack of compliance in following titers regularly, and poorly defined at-risk categories.7,8 Current recommendations include two doses of PrEP, one on day zero and another on day seven. They only recommend checking one’s titer once within one to three years of vaccination or obtaining another booster within three weeks to three years of vaccination post-initial series.7–10 With the updated CDC recommendations, individuals may choose to forgo titers or follow them closely. Consider your risk level, exposure level, any underlying conditions that may dampen immune response, the availability of vaccination, and other factors to determine what works for you. Initially vaccinated in 2000, I had titers every two years and watched the levels wane. A few years ago, my titer was undetectable. Had I followed the CDC’s recommendations, I may not have had protection, and were I exposed, would the post-exposure prophylaxis (PEP) for a vaccinated individual have been enough? I didn’t want to find out the hard way, so I had my rabies vaccination recently boostered. Consider your vaccination status, risk level, and staff’s risk level, and implement effective strategies for you. Post-exposure prophylaxis (PEP) A protocol should be in place in all veterinary hospitals addressing what staff should do if an animal bites them. This needs to include:6,7 Washing and cleaning the wound thoroughly Filing an incident report and reporting it to the appropriate person Seeking medical attention (bite wounds should be taken seriously; while more common with cat bites than dog, the infection can seed rapidly and lead to systemic spread if left untreated) Ensure the staff member is comfortable with resuming work, doesn’t need counseling, and is medically cleared to return to work Protocol for what information is given to clients who have pets bitten where vaccine status is unknown or when their vaccine has lapsed, the transmission time, and more Protocol for what information to give clients whose dog bit a person (this information will vary with locality and laws in the area) Advise owners with known wildlife attacks, if they call ahead, to bring the attacker, if feasible and safe to do so for rabies testing or to contact a local animal control authority (if available) for assistance with the wildlife component Advise owners bringing in pets with wounds of unknown origin to wear gloves if feasible and avoid contact with the dog (saliva could be all over the animal, and being the means of transmission, safety precautions are warranted) In addition to standard operating procedures (SOPs) or protocols for handling various scenarios, ensure staff understand how to remove a head for testing properly and how to package and ship it. Ensure biosecurity measures are taken, including clothing, hands, eyes, face, feet, and head protection. Proper personal protective equipment (PPE) is required to remove the head, given that this is a highly fatal zoonotic disease. Finally, PEP may be warranted if an owner, staff member, or bystander is bitten by an animal with an unknown rabies status and that animal is not available for rabies testing. Speak to your healthcare professionals and, if available, the public health department in your area. Human healthcare facilities often know little about PEP, do not have the vaccine/rabies immunoglobulin (RIG) available, and aren’t trained on administration and protocols. PEP consists of proper wound management, rabies vaccination, and booster, and RIG is generally administered if previously unvaccinated at the time of exposure.6,11 Controlling rabies: One Health collaboration Rabies, one of the most notorious viral diseases known to the animal kingdom, sadly has been around a long time and is likely here to stay. However, with client education, continued vaccination campaigns (for domestic animals and wildlife), due diligence, importation laws that hinder the reintroduction of the canine variant into the U.S., and cooperative efforts with physicians, researchers, biologists, and more, we can continue to dampen the ill effects of rabies and its reach. Rabies represents a prime example of how the collaborative efforts of stakeholders in the veterinary, human health, and environmental fields can come together to mitigate a problem, lessen the disease’s risk of spread, and improve post-exposure precautions. Ensuring you remain vigilant; keeping rabies on your differential list for neurological abnormalities; having a high index of suspicion with juvenile animals, strays, wounds of unknown origin; and taking appropriate precautions, including reporting it and ensuring you follow the laws in your area, remains paramount to protecting clients, patients, staff, and those around us. Erica Tramuta-Drobnis, VMD, MPH, CPH, is the CEO and founder of ELTD One Health Consulting, LLC (https://eltdonehealth.com/). Dr. Tramuta-Drobnis works as a public health professional, emergency veterinarian, freelance writer, consultant, and researcher. She is passionate about One Health issues and believes pet health, food safety, agricultural health, and more can address the interconnection of human, animal, and environmental health. References Wasik B, Murphy M. Rabid: A Cultural History of the World’s Most Diabolica…. Viking; 2012. Accessed September 19, 2024. https://www.goodreads.com/book/show/13403051-rabid Dall N. Why are Cape fur seals in South Africa infected with rabies? Al Jazeera. September 7, 2024. Accessed September 18, 2024. https://www.aljazeera.com/features/2024/9/7/why-are-cape-fur-seals-in-south-africa-getting-infected-with-rabies Centers for Disease Control & Prevention (CDC). Rabies in the United States: Protecting Public Health. Rabies. July 31, 2024. Accessed September 18, 2024. https://www.cdc.gov/rabies/php/protecting-public-health/index.html American Society for Microbiology. The One Health of Rabies: It’s Not Just for Animals. ASM.org - American Society for Microbiology. September 27, 2021. Accessed May 10, 2022. https://asm.org/Articles/2021/September/The-One-Health-of-Rabies-It-s-Not-Just-for-Animals Snapshot. Accessed September 18, 2024. https://www.cdc.gov/rabies/php/protecting-public-health/index.html Brown CM, Slavinski S, Ettestad P, Sidwa TJ, Sorhage FE. Compendium of Animal Rabies Prevention and Control, 2016. Published online March 1, 2016. doi:10.2460/javma.248.5.505 Tramuta-Drobnis EL. Are modified rabies recommendations backed by the latest scientific findings? Vet Pract News. 2023;35(2):26-29. Rao AK, Briggs D, Moore SM, et al. Use of a Modified Preexposure Prophylaxis Vaccination Schedule to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71. doi:10.15585/mmwr.mm7118a2 American Veterinary Medical Association (AVMA). CDC updates recommendation for human rabies vaccination. American Veterinary Medical Association. October 4, 2022. Accessed November 30, 2022. https://www.avma.org/news/cdc-updates-recommendation-human-rabies-vaccination Centers for Disease Control & Prevention (CDC). Pre-exposure Prophylaxis (PrEP). Centers for Disease Control and Prevention. May 5, 2022. Accessed November 30, 2022. https://www.cdc.gov/rabies/prevention/pre-exposure_vaccinations.html Xu C, Lau CL, Clark J, et al. Immunogenicity after pre- and post-exposure rabies vaccination: A systematic review and dose-response meta-analysis. Vaccine. 2021;39(7):1044-1050. doi:10.1016/j.vaccine.2021.01.023

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Time to look at rabies with a One Health lens

Reviewing essential facts for veterinary practice to boost understanding and eradication

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