Meeting the urgent need for rabies education in Haiti.

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

Immune response after rabies vaccine in a kidney transplant recipient.

A 48-year-old male kidney-transplant recipient was bitten by a rabid dog. His immunosuppressive treatment consisted of cyclosporine 60 mg b.i.d., mycophenolate mofetil (MMF) 250 mg t.i.d., and prednisone 5 mg. After wound care, he received 5 doses of purified vero cell rabies vaccine on days 0, 3, 7, 14, and 28, and human rabies immunoglobulin, according to international guidelines. Adequate levels of rabies virus neutralizing antibodies were observed after the administration of the third vaccine dose. However, a decrease of antibody titer was detected by day 28. Immunosuppressive medication was minimized, withdrawing MMF and reducing the dose of cyclosporine. Booster doses of the same vaccine were administered on days 38, 41, 45, 52, and 66. Adequate neutralizing antibody response was recovered during the ensuing 12 months, under reduced immunosuppression. Nineteen months after the incident, the patient remains with good graft function and is asymptomatic for rabies. It remains to be determined whether the attained immune response was either the result of the booster vaccinations or the reduction of immunosuppression alone. Nevertheless, such an outcome would have been possible only with the combined management strategy implemented.

Attaining raccoon rabies management goals: history and challenges.

Prior to 1977, raccoon (Procyon lotor) rabies was confined to the southeastern US. Translocations led to emergence of this rabies variant in the mid-Atlantic states, followed by spread northerly to northeast Ohio and Ontario, Quebec, and New Brunswick, Canada. Raccoon rabies is currently contiguous from southwest Alabama to southeastern Canada. Since 1998, state, federal, county and municipal as well as Canadian and Mexican experts have collaborated on goals and strategies to prevent raccoon rabies spread in North America. Coordinated programmes have been established from Maine to Alabama. Successes have been realized through strategies that rely heavily on oral vaccination. International coordination targeting raccoon rabies continues in eastern Canada, where contingency actions have led to elimination or near elimination in Ontario and New Brunswick. However, increasingly, focus in the US has been directed toward contingency actions to "hold-the-line" where raccoon rabies threatens to spread to new areas, rather than on raccoon rabies elimination. We report on the challenges of achieving enhanced rabies surveillance, containment of raccoon rabies, and local elimination of raccoon rabies, as well as the need for international coordination in meeting these challenges.

Rabies surveillance in the United States during 2000.

During 2000, 49 states, the District of Columbia, and Puerto Rico reported 7,364 cases of rabies in nonhuman animals and 5 cases in human beings to the Centers for Disease Control and Prevention, an increase of 4.3% from 7,067 cases in nonhuman animals reported in 1999. Ninety-three percent (6,855 cases) were in wild animals, whereas 6.9% (509 cases) were in domestic species (compared wth 91.5% in wild animals and 8.5% in domestic species in 1999). Compared with cases reported in 1999, the number of cases reported in 2000 increased among bats, dogs, foxes, skunks, and sheep/goats and decreased among cats, cattle, horses/mules, raccoons, and swine. The relative contributions of the major groups of animals were as follows: raccoons (37.7%; 2,778 cases), skunks (30.2%; 2,223), bats (16.8%; 1,240), foxes (6.2%; 453), cats (3.4%; 249), dogs (1.6%; 114), and cattle (1.1%; 83). Ten of the 19 states where the raccoon-associated variant of the rabies virus has been enzootic reported increases in the numbers of cases of rabies during 2000. Among those states that have engaged in extensive wildlife rabies control programs, no cases of rabies associated with the epizootic of rabies in raccoons (or in any other terrestrial species) were reported in Ohio, compared with 6 cases reported in 1999. No rabies cases associated with the dog/coyote variant (compared with 10 cases in 1999, including 5 in dogs) were reported in Texas, and cases associated with the gray fox variant of the virus decreased (58 cases in 2000, including 38 among foxes). Reports of rabid skunks exceeded those of rabid raccoons in Massachusetts and Rhode Island, states with enzootic raccoon rabies, for the fourth consecutive year. Nationally, the number of rabies cases in skunks increased by 7.1% from that reported in 1999. The greatest numerical increase in rabid skunks (550 cases in 2000, compared with 192 in 1999) was reported in Texas. The number of cases of rabies reported in bats (1,240) during 2000 increased 25.4% over the number reported during 1999 (989) and represented the greatest contribution (16.8% of the total number of rabid animals) ever recorded for this group of mammals. Cases of rabies reported in cattle (83) and cats (249) decreased by 38.5% and 10.4%, respectively, whereas cases in dogs (114) increased by 2.7% over those reported in 1999. Reported cases of rabies among horses and mules declined 20% from 65 cases in 1999 to 52 cases in 2000. Four indigenously acquired cases of rabies reported in human beings were caused by variants of the rabies virus associated with bats. One case of human rabies acquired outside the United States that resulted from a dog bite was caused by the canine variant of the rabies virus.

Rabies surveillance in the United States during 1999.

During 1999, 49 states, the District of Columbia, and Puerto Rico reported 7,067 cases of rabies in nonhuman animals to the Centers for Disease Control and Prevention, a decrease of 11.2% from 7,961 cases in nonhuman animals and 1 case in a human being reported in 1998. More than 91% (6,466 cases) were in wild animals, whereas 8.5% (601 cases) were in domestic species (compared with 92.4% in wild animals and 7.6% in domestic species in 1998). No cases of rabies were reported in human beings in 1999. Decreases were evident in all major species groups, with the exception of cattle, sheep/goats, and swine. The relative contributions of the major groups to the total reported were as follows: raccoons (41.0%; 2,872 cases), skunks (29.4%; 2,076), bats (14.0%; 989), foxes (5.4%; 384), cats (3.9%; 278), cattle (1.9%; 135), and dogs (1.6%; 111). Reported cases (6) associated with the epizootic of rabies in raccoons in Ohio declined from the 26 cases reported in 1998. Fifteen of the 19 states where the raccoon variant of the rabies virus is enzootic reported fewer cases of rabies during 1999. Massachusetts and Rhode Island, states with enzootic rabies in raccoons, each reported more rabid skunks than rabid raccoons for the third consecutive year. In Texas, cases associated with the enzootic canine variants of the rabies virus remained low (10 cases), whereas cases associated with the gray fox variant of the virus increased (66). Cases of rabies in skunks decreased by 8.6%, compared with those reported in 1998. Michigan reported the largest percentage increase in rabid skunks (950.0%; 2 cases in 1998 to 21 in 1999). Cases of rabies in horses and mules declined 21%, from 82 cases in 1998 to 65 in 1999. Cases of rabies reported in bats (989) were similar in number to those reported in 1998 (992) and represented almost 14.0% of the total number of rabid animals reported during 1999. Reported cases of rabies in cats (278) and dogs (111) decreased by 1.4% and 1.8%, respectively, whereas cases in cattle (135) increased by 16.4%, compared with those reported in 1998.

Rabies surveillance in the United States during 1998.

During 1998, 49 states, the District of Columbia, and Puerto Rico reported 7,961 cases of rabies in nonhuman animals and 1 case in a human being to the Centers for Disease Control and Prevention, a decrease of 6.5% from 8,509 cases in nonhuman animals and 4 cases in human beings reported in 1997. More than 92% (7,358 cases) were in wild animals, whereas > 7.5% (603 cases) were in domestic species (compared with 93% in wild animals and 7% in domestic species in 1997). Decreases were evident in all of the major contributing species groups, with the exception of skunks and bats. The relative contributions of the major groups to the total reported for 1998 were reccoons (44.0%; 3,502 cases), skunks (28.5%; 2,272), bats (12.5%; 992), foxes (5.5%; 435), cats (3.5%; 282), cattle (1.5%; 116), and dogs (11.5%; 113). No further discernable westward extension of the epizootic of rabies in raccoons in Ohio was reported. Twelve of the 19 states enzootic for the raccoon variant of the rabies virus and the District of Columbia reported decreased numbers of cases of rabies during 1998, compared with 13 states and the District of Columbia that reported increases during 1997. Three states, Rhode Island (143.2%), Massachusetts (77.2%), and New Hampshire (69.4%), reported increases of > 50% during 1998, compared with totals reported for 1997. In Texas, the number of cases of rabies associated with enzootic canine variants of the rabies virus remained greatly diminished; however, overall totals of reported cases of rabies increased in Texas and 12 other states where skunks are the major terrestrial reservoir of rabies. At the national level, the total of 82 reported cases of rabies among horses and mules was greater than that reported for any year since 1981 (88 cases) and represented a 74.5% increase, compared with the total for 1997. The 992 cases of rabies reported in bats during 1998 were the greatest proportionate contribution by bats since 1990. Reported cases of rabies in cats (282), dogs (113), and cattle (116) decreased 6.0%, 10.3%, and 4.9%, respectively. One indigenously acquired case of rabies reported in a human being during 1998 was the result of infection with a rabies virus variant associated with silver-haired and eastern pipistrelle bats.

Laboratory investigation of human deaths from vampire bat rabies in Peru.

In the spring of 1996, multiple cases of an acute febrile illness resulting in several deaths in remote locations in Peru were reported to the Centers for Disease Control and Prevention (CDC). The clinical syndromes for these cases included dysphagia and encephalitis. Because bat bites were a common occurrence in the affected areas, the initial clinical diagnosis was rabies. However, rabies was discounted primarily because of reported patient recovery. Samples of brain tissue from two of the fatal cases were received at CDC for laboratory confirmation of the rabies diagnosis. An extensive array of tests on the formalin-fixed tissues confirmed the presence of both rabies viral antigen and nucleic acid. The virus was shown to be most closely related to a vampire bat rabies isolate. These results indicate the importance of maintaining rabies in the differential diagnosis of acute febrile encephalitis, particularly in areas where exposure to vampire bats may occur.

Rabies surveillance in the United States during 1997.

In 1997, 49 states, the District of Columbia, and Puerto Rico reported 8,509 cases of rabies in nonhuman animals and 4 cases in human beings to the Centers for Disease Control and Prevention. Nearly 93% (7,899) were wild animals, whereas 7% (610) were domestic species. The total number of reported cases increased 19.4% from that of 1996 (7,128 cases). Increases were apparent in each of the major species groups, with the exception of cattle. The relative contributions of these groups to the total reported for 1997 were as follows: raccoons (50.5%; 4,300 cases), skunks (24.0%; 2,040), bats (11.3%; 958), foxes (5.3%; 448), cats (3.5%; 300), dogs (1.5%; 126), and cattle (1.4%; 122). The 958 cases of rabies reported in bats represented a 29.3% increase over the total reported for 1996 and the greatest number reported since 1984, with cases reported by 46 of the 48 contiguous states. The epizootic of rabies in raccoons expanded into Ohio in 1997 and now includes 19 states and the District of Columbia. Thirteen states, where rabies in raccoons is enzootic, reported increases over 1996 in total numbers of reported cases. New York (1,264 cases), North Carolina (879), Virginia (690), and Maryland (619) reported the greatest numbers of cases [corrected]. Five states reported increases that exceeded 50%, compared with cases reported in 1996: Ohio (673.3%; 15 cases in 1996 to 116 in 1997). Massachusetts (144.3%; 115 to 281), South Carolina (97.9%; 96 to 190), Connecticut (97.4%; 274 to 541), and Maine (86.3%; 131 to 244). Cases of rabies associated with foci of rabies in foxes in west central Texas and in dogs and coyotes in southern Texas continued to decline, with this state reporting 78.3% fewer rabid foxes (13 cases), 26.7% fewer rabid dogs (11), and 63.2% fewer rabid coyotes (7) during 1997, compared with 1996. Reported cases of rabies in cats (300) and dogs (126) increased 12.8% and 13.5%, respectively, whereas cases in cattle (122) decreased by 6.9%. Thirty states, the District of Columbia, and Puerto Rico reported increases in rabies in animals during 1997, compared with decreases reported by 31 states and the District of Columbia in 1996. One state (Mississippi; 5 cases) remained unchanged. Hawaii was the only state that did not report a case of rabies in 1997. Four indigenously acquired cases of rabies reported in human beings were the result of infection with rabies virus variants associated with bats.

Rabies surveillance in the United States during 1996.

In 1996, 49 states, the District of Columbia, and Puerto Rico reported 7,124 cases of rabies in non-human animals and 4 cases in human beings to the Centers for Disease Control and Prevention. Nearly 92% (6,550 cases) were wild animals, whereas 8% (574 cases) were domestic species. The total number of reported cases decreased 9.6% from that of 1995 (7,881 cases). Although much of the decline was the result of fewer reported cases of rabies in raccoons, fewer cases were also reported among most groups of animals. Numbers of cases associated with separate epizootics of rabies in foxes in west central Texas and in dogs and coyotes in southern Texas attributable to canine variants have declined, with 56.2% fewer rabid foxes (60), 72.7% fewer rabid dogs (15), and 76.3% fewer rabid coyotes (19) during 1996, compared with cases of rabies reported among these same species during 1995. Nationally, the number of reported rabid bats (741) decreased 5.8%, with cases reported by 46 of the 48 contiguous states. Four Eastern Seaboard states, enzootic for the raccoon variant of the rabies virus, reported noteworthy increases in total numbers of reported cases: Maine (29.7%; 101 cases in 1995 to 131 in 1996), Maryland (44.2%; 441 to 636), North Carolina (59.0%; 466 to 741), and Virginia (33.3%; 459 to 612). Increases were also reported by Florida (6.4%; 251 to 267) and Georgia (3.1%; 294 to 303). Cats continued to be the domestic animal most frequently reported rabid, but reported cases of rabies in cats (266), cattle (131), and dogs (111) decreased by 7.6%, 3.7%, and 24.0%, respectively. Thirty-one states and the District of Columbia reported decreases in rabies in animals during 1996, compared with 18 states and Puerto Rico in 1995. Hawaii was the only state that did not report a case of rabies in 1996. Two indigenously acquired cases of rabies reported in human beings were the result of infection with rabies virus variants associated with bats, whereas the remaining 2 human rabies infections were acquired outside the United States, and the variants identified were consistent with those associated with rabid dogs.

Rabies surveillance in the United States during 1995.

In 1995, 49 states, the District of Columbia, and Puerto Rico reported 7,877 cases of rabies in nonhuman animals and 4 cases in human beings to the Centers for Disease Control and Prevention. Nearly 92% (7,247 cases) were wild animals, whereas 8% (630 cases) were domestic species. The total number of reported cases decreased 4.2% from that of 1994 (8,230 cases). Most of the decline was the result of 17.1% fewer reported cases of rabies in raccoons in areas of the Northeast, where rabies is now enzootic rather than epizootic. Exceptions to this decline were detected in states where the virus has only recently entered raccoon populations or where ongoing epizootics persist. States experiencing increasing epizootic activity associated with this variant include Maine (3 cases in 1993 to 101 cases in 1995), North Carolina (9 cases in 1990 to 466 cases in 1995), Rhode Island (1 case in 1993 to 324 cases in 1995), and Vermont (45 cases in 1993 to 179 cases in 1995). The raccoon variant of the rabies virus is now present in Alabama, Pennsylvania, Vermont, West Virginia, and all Atlantic Seaboard states from Florida to Maine. In Ohio, this variant, last detected in 1992 as a single case, was again detected in 1996. Epizootics of rabies in foxes in west central Texas and in dogs and coyotes in southern Texas attributable to canine variants continue, with this state reporting 137 rabid foxes, 55 rabid dogs, and 80 of the 83 cases in coyotes during 1995. The number of rabid bats (787) increased by almost 25%, with cases reported by 47 of the 48 contiguous states. Nationally, reported cases of rabies in cattle (136) and cats (288) increased by 22.5 and 7.9%, respectively, whereas cases in dogs (146) decreased by 4.6%. Cats continued to be the domestic animal most frequently reported rabid. The cases of rabies reported in human beings were all caused by viral variants associated with bats. Eighteen states and Puerto Rico reported decreases in rabies in animals in 1995, compared with 28 states and the District of Columbia in 1994. Hawaii was the only state that did not report a case of rabies in 1995.

Rabies surveillance in the United States during 1994.

In 1994, 48 states, the District of Columbia, and Puerto Rico reported 8,224 cases of rabies in nonhuman animals and 6 cases in human beings to the Centers for Disease Control and Prevention. Nearly 93% (7,632 cases) were wild animals, whereas 7% (592 cases) were domestic species. The total number of reported cases decreased 13.4% from that of 1993 (9,498 cases), with most of the decline resulting from 19.2% fewer cases of rabies in raccoons. Two previously described epizootics of rabies involving the raccoon variant of the rabies virus have converged in North Carolina, and the resulting region is now continuous from Alabama and Florida in the South to Maine in the North. Epizootics of rabies in foxes in west central Texas and in dogs and coyotes in southern Texas continue to expand, with this state reporting 144 rabid foxes, 53 rabid dogs, and 77 of the 85 cases in coyotes during 1994. Maine and New Hampshire reported cases of rabies in foxes (6 and 9, respectively) for the first time in 10 years. Nationally, reported cases of rabies in dogs (153) increased by 17.7%, whereas cases in cattle (111) and cats (267) decreased by 14.6 and 8.3%, respectively. Cats continued to be the domestic animal most frequently reported rabid. Twenty-eight states and the District of Columbia reported decreases in rabies in animals in 1994, compared with 22 states, the District of Columbia, and Puerto Rico in 1993. Hawaii and Nebraska were the only states that did not report cases of rabies in 1994.

Rabies surveillance in the United States during 1993.

In 1993, 49 states, the District of Columbia, and Puerto Rico reported 9,495 cases of rabies in nonhuman animals and 3 cases in human beings to the Centers for Disease Control and Prevention. Greater than 93% (8,889 cases) were wild animals, whereas 6.4% (606 cases) were domestic species. The total number of reported cases increased 9.9% over that of 1992 (8,645 cases), with most of the increase resulting from continued spread of rabies in raccoons (37.1% increase in reported cases over 1992). The 2 epizootics of rabies in raccoons (Northeastern/mid-Atlantic and Southeastern regions) approach convergence in North Carolina (106 cases of rabies in 1993, compared with 49 in 1992). Maine, Rhode Island, and Vermont remained the only New England states without reported cases associated with the raccoon variant of the rabies virus. New York reported 2,747 cases of rabies, the largest number of cases ever reported during a single year by any state. Increases in reported cases of rabies in Texas and 8 other geographically dispersed states were attributed mainly to larger numbers of reported cases of rabies in bats. Texas reported 71 of the 74 cases in coyotes during 1993 (70 of 75 cases in 1992). Nationally, reported cases of rabies in dogs (130) and cattle (130) each decreased by 29% in 1993, whereas cats (291 cases in 1993, compared with 290 in 1992) continued to be the domestic animal most frequently reported rabid. Twenty-two states and Puerto Rico reported decreases in rabies in animals in 1993, compared with 20 states, the District of Columbia, and Puerto Rico in 1992. Hawaii was the only state that did not report a case of rabies in 1993.

Unexplained rabies in three immigrants in the United States. A virologic investigation.

BACKGROUND: Extensive investigation of three patients who died of rabies in the United States failed to reveal any source of exposure to the disease. The three patients had immigrated to the United States from areas in Laos, the Philippines, and Mexico where rabies is endemic. METHODS: We studied rabies viruses isolated from the three patients, other patients with a known source of exposure, and animals in the United States, Thailand (as a proxy for Laos), the Philippines, and Mexico. The viruses were characterized by indirect immunofluorescence and neutralization tests according to their reactions to panels of monoclonal antibodies. Transcribed complementary DNA from these isolates was amplified by the polymerase chain reaction; the DNA product was then analyzed by differential digestion with restriction enzymes. RESULTS: The viral isolate from each of the three patients was a rabies variant with distinctive antigenic or genetic characteristics. For each of the three isolates, identical variants were found in specimens from rabid animals obtained from or near the country in which the patient lived before immigrating to the United States. None of these variants were found among the isolates collected from rabid animals in the United States. CONCLUSIONS: Rabies infection in these three patients did not originate in the United States but resulted from exposures in Laos, the Philippines, and Mexico. Since the three patients had lived in the United States for 4 years, 6 years, and 11 months, our findings suggest that the onset of the clinical manifestations of rabies occurred after long incubation periods.