Rabies Active Surveillance Protocol

1. Ensure that personnel who will perform brain stem extractions are educated about rabies, rabies transmission and exposure, pre-exposure vaccination and post-exposure vaccination (PEP). (Appendix 1: Information for Workers Performing Brainstem Extraction for Active Surveillance-Rabies in Wildlife), (Appendix 2: Rabies Vaccine: What You Need to Know). [State Public Health Veterinarian or designee].

2. Ensure that staff are appropriately trained in performance of brain stem extraction procedure, including appropriate safety precautions. [State Public Health Veterinarian or designee].

3. Ensure personnel receiving pre-exposure rabies vaccination are appropriately screened for contraindications prior to vaccination and are educated about possible vaccine reactions. [LHD Public Health Nurse].

4. Ensure personnel who are performing brain stem extractions receive pre-exposure rabies vaccination, according to Advisory Committee on Immunization Practices (ACIP) recommendations (Appendix 3. MMWR: Human Rabies Prevention-United States 1999, Jan 8, 1999, vol. 48, No. RR-1). [LHD Public Health Nurse].

5. Ensure signed documentation of education, training, pre-screening and vaccination is placed in each employees file who receives rabies vaccine and participates in brainstem removal activities (Appendix 4: Rabies Vaccination Checklist).

6. Submit a maximum of 8 brain stem samples per month from each of the active surveillance counties to the Office of Laboratory Services (OLS) for rabies testing.

7. On an annual basis educate the public about rabies, the Oral Rabies Vaccination (ORV) program and active surveillance , especially recognition of target species that are potentially infected with the rabies virus.

8. On an annual basis educate local government officials, physicians, veterinarians and the general public about the ORV program with regard to aerial distribution and vaccine safety.

9. Ensure that all persons who receive pre-exposure vaccination have their immune titers checked every 2 years and receive booster vaccination if titers fall below recommended levels.

1. Prevent the westward spread of raccoon strain rabies in WV by appropriate placement, determined through active surveillance, of an ORV barrier.

1. To identify geographic location of each case of raccoon strain rabies (RSR).

2. To determine where RSR is occurring in WV and identify the western edge of the epizootic throughout the length of WV.

3. Evaluate surveillance data to identify appropriate placement for the ORV barrier.

West Virginia has a population of 1.8 million people, and is one of the two most rural states in the nation. Since raccoon rabies was first identified within our borders in 1977, the epizootic has extended throughout the eastern panhandle, and across the continental divide. This epizootic now threatens the Ohio River valley leading to the Midwestern United States; and the New River Gorge, leading to Charleston.

During the years prior to Year 2001, West Virginia had about 100 cases of raccoon rabies per year using passive surveillance (submission of specimens when there has been a human or domestic animal exposure). Therefore the location of the true ‘leading edge’ of the epizootic was unknown. During the year 2001, active surveillance was initiated in 20 West Virginia counties as part of the USDA funded Oral Rabies Vaccination Program. These counties were chosen because they were adjacent to counties where raccoon rabies had been identified previously. In 2002 and 2003 surveillance was extended to include 29 counties, the original 20 counties plus 9 additional counties that were within the oral vaccine distribution area. Active surveillance will continue in these 29 counties until surveillance indicates otherwise. The 29 counties are:

Active surveillance during the year 2001 revealed 7 rabies positive raccoons in 4 counties

where rabies had not been known previously (3 Raleigh, 2 Webster, 1 each in Fayette and Nicholas). In 2002, a positive raccoon was found in Braxton County (on the border with Lewis County, a county where rabies had been identified previously) through passive surveillance. Since 2002 no new counties have been found positive for RSR.

In animals there are no known definitive or species-specific clinical signs of rabies beyond acute behavioral alterations; "the abnormal becomes typical". Severity and variation of signs may be related to the specific site(s) of the primary CNS lesion. At the end of the incubation period, the disease progresses through a short prodromal state to encephalopathy and death, usually within days.

Initial signs of rabies are nonspecific and may include anorexia, lethargy, fever, dysphagia, vomiting, diarrhea, straining to urinate and defecate. Alteration in behavior, such as increasing aggressiveness and vocalization are common. In addition to behavioral abnormalities, cranial and peripheral nerve deficits may occur. Most animals die within one week to 10 days of symptom onset.

Organ transplants taken from persons dying of undiagnosed CNS disease have resulted in rabies in the recipients. Airborne spread has been demonstrated in a cave where myriad of bats were roosting and in laboratory settings, but this occurs very rarely. In the USA, rabid insectivorous bats rarely transmit rabies to terrestrial animals, wild or domestic.

Incubation period in most animal species is unknown. However, periods of less than 10 days to several months are well documented. As with humans, severe and multiple bites to the head and neck and bites to highly innervated areas may result in shorter incubation periods.

Domestic dogs, cats and ferrets are the only animals with scientifically documented viral shedding periods in saliva. Virus may be shed for up to 10 days prior to onset of clinical signs in these animal. There are no available data for other animal species.

Persons collecting brainstem specimens are required to obtain pre-exposure rabies vaccination and training prior to collecting samples. Signed documentation of vaccination and training should be placed in the employees file (refer to Public Health Actions section)

1. Raccoons, foxes, skunks and coyotes that are exhibiting signs consistent with rabies, found dead or as roadkill. Signs consistent with rabies include:

• loss of apparent wariness of humans and domestic animals

• unprovoked agitation and extreme aggression toward animate or inanimate objects

• head tilt, head pressing or butting and "star gazing"

• signs of self-mutilation

• no apparent response to pain

• paralysis of limbs and facial muscles

• change in normal behavior patterns (i.e., out during daylight hours)

2. Handling target species

1. If euthanasia is necessary, it should be performed by a professional with experience in handling or dispatching wild animals.

2. Complete a Rabies Submission Form (Appendix 5) for each specimen.

1. Put on personal protective equipment:

• face shield or surgical mask and goggles
• double glove
• surgical gown if desired

2. Using a permanent marker pen label the specimen collection tin with:

3. With animal on its back, use a disposable scalpel to make an incision from the tip of the lower jaw extending approximately 2 inches below the point where head and neck join.

4. Sever the muscular attachments of the tongue along both sides, using the lower jawbone as a guide, and continue cutting caudally to free the larynx, trachea and esophagus as a single unit.

5. Retract this unit to expose the ventral surface of the spinal column and associated musculature.

6. With one hand flex the head while using a finger from the other hand to feel the place where the head and neck join (atlantoccipital joint).

7. Dissect tissue in order to further expose the surface of the joint.

8. Access to brainstem appears as a "small window" covered by a thin layer of connective tissue.

9. To increase access to the brainstem enclosed in the boney canal joint, cut through the connective tissue on either side of the joint while flexing the head to permit better access.

10. The exposed brainstem/spinal cord tissue should be cut as close to the large opening into the skull (foramen magnum) as possible. Place the final cut to make a section of brainstem approximately 1/4 inch.

11. Place the brainstem specimen into the open collection tin and secure the lid. Wipe the outside of the specimen tin with disinfectant and place it inside a plastic zip-lock. Attach the corresponding Rabies Submission Form securely to the specimen (either on the outside of the zip-lock or double bag the container and place the form inside the second zip-lock).

12. The carcass and disposable personal protection equipment (e.g., gloves and surgical gown) should be placed into a thick ply trash bag (not a red bio-hazard bag) and discarded in a dumpster or landfill.

13. Decontaminate all working surfaces and equipment with disinfectant.

14. Wash hands with hand sanitizer or soap and water.

15. Specimens should be submitted to the Office of Laboratory Services (OLS) according to current shipping regulations (see OLS manual). If specimens are not sent immediately to OLS they may be stored in a regular freezer (not frost free, as they have freeze and thaw cycles to remain frost free) for less than a week prior to shipping.

Brain tissue samples that are positive by immunoflourescent antibody testing are considered diagnostic.

The standard test for detecting rabies is an immunoflourescent antibody (IFA) test on brain tissue. Any brain tissue sample that tests positive by IFA is considered positive for rabies and will be further tested with monoclonal antibodies to determine which strain of rabies is involved.

Brainstem samples should be sent to the West Virginia Office of Laboratory Services (OLS), 167 11^th Ave, South Charleston, WV 25303 for testing. Sharon Hill (304-558-3530) should be contacted in regard to questions about active surveillance testing. The specimen should be accompanied by a completed Rabies Submission Form (Appendix 5) when sent to the OLS.

Prior to vaccination personnel should be screened for potential contraindication, advised of potential adverse reactions and informed of how to deal with reactions if they occur. Signed documentation of the following should be placed in each participating employees file:

• education on rabies pre and post-exposure vaccination, including screening and information on adverse reactions
• vaccine administration according to ACIP recommendations

2. Pre-exposure Vaccination and Serologic Testing
   Because the antibody response has been satisfactory after these recommended pre-exposure prophylaxis vaccine regimens, routine serologic testing to confirm seroconversion is not necessary except for persons suspected of being immunosuppressed. Patients who are immunosuppressed by disease or medications should postpone pre-exposure vaccinations and consider avoiding activities for which rabies pre-exposure prophylaxis is indicated. When that is not possible, immunosuppressed persons who are at risk for exposure to rabies should be vaccinated and their antibody titers checked. In these cases, failures to seroconvert after the third dose should be managed in consultation with appropriate public health officials.

• Number of active surveillance specimens per month sent to OLS for testing (goal is 8 brainstem submissions per month) from each participating county

• Proportion of submissions with GIS locating information

• Proportion of submissions with complete rabies submission form