Vital Signs: Rabies Transcript

OPERATOR: Welcome and thank you for standing by.  At this time all participants are in a listen-only mode until the question and answer session of today’s conference.  To ask a question from the phone lines please press star 1 and record your name when prompted.  This call is being recorded.  If you have any objections please disconnect at this time.  I would now like to turn the call over to your host, Kathy Harben.  You may begin.

KATHY HARBEN: Thank you, Victor.  And thank you, everyone, for joining us today for the release of a new CDC “Vital Signs,” this one is on rabies risks and threats in the U.S.  We are joined by CDC Principal Deputy Director Dr. Anne Schuchat, and we also have Dr. Emily Pieracci.  She’s a veterinarian in CDC’s Rabies program.  Dr. Schuchat and Dr. Pieracci will also be available for the media Q&A portion of this briefing.  I’ll turn the call over now to Dr. Schuchat.

DR.ANNE SCHUCHAT: Good afternoon and thanks for joining us today. As you know, each month in CDC’s “Vital Signs” report we focus on a health threat and what can be done about it. This report today focuses on rabies risks in the United States, what has changed and what you can do to protect yourself from the disease.  Rabies infection is nearly always fatal.  So we take extensive measures to prevent this deadly viral illness.  The U.S has had great success at preventing and controlling rabies during the past 80 years.  Vaccination of dogs and the availability of post-exposure prophylaxis, or PEP, the vaccine and medicine people get to prevent rabies if they may have been exposed to a rabid animal, contributed to a 95% decrease in annual rabies deaths in people.  About 55,000 Americans receive post-exposure prophylaxis in emergency departments each year, and most dogs and cats receive annual rabies shots to keep them protected.  More than a million dogs enter the U.S annually, including over 100,000 that are imported from countries where canine rabies virus variant is still found.  Dramatic shifts have occurred in the United States in which animals pose the most risk for human rabies.  Mass dog vaccination programs started in the 1950s, and by 2004 these programs had eliminated the type of rabies that normally circulates in dogs.  Wildlife reservoirs for rabies are still present in the United States and exposure to an infected animal can be deadly.  Extensive effort by animal and human health workers have resulted in an average of one to three human deaths from rabies each year in the U.S., down from about 50 per year before the 1950s.  The two most common ways that people get rabies in the United States today are through bites and scratches from infected wildlife like bats, raccoons, skunks and foxes, or from rabid dogs they may encounter while they’re traveling outside the U.S.  Any mammal can catch rabies.  Among all rabid animals detected in the United States, 32% are bats, 28% are raccoons, 21% are skunks, 7% are foxes, and 6% are cats.  Unvaccinated dogs can still get rabies from wildlife, but currently dogs make up only about 1% of the reported rabies cases in animals in the United States.  Bats in the U.S. are especially a concern.  People may not realize that bats carry rabies, so they may not see their medical provider after touching or handling a bat.  Bat bites are small, smaller than the top of a pencil eraser, and so they can go unnoticed.  This is a problem because rabies is deadly once symptoms start.  Recognizing the risk and getting treatment fast is important.  Starting in 2015, the number of rabid bats reported surpassed the number of raccoons for the first time, and the gap has been widening ever since.  Bats made up about 32% of the roughly 5,000 rabid animals tested in 2017 while raccoons made up 28%.  In the United States although bats make up about a third of all rabid animals reported they are responsible for more than 2/3 of all rabies deaths in people.  That is, 7 in 10 Americans who die from rabies in the United States were infected by bats.  We want this “Vital Signs” to raise awareness about specific rabies risks so people can take steps to protect themselves from rabies.  The bottom line is rabies continues to be a threat in the U.S. and abroad and people should see their health care professional if they think they’ve been bitten or scratched by an animal and before symptoms occur.  An ounce of prevention can go a long way.  Now Dr. Emily Pieracci is going to share more of today’s report’s findings.

DR. EMILY PIERACCI: Thank you, Dr. Schuchat. In this “Vital Signs” CDC reports on trends in nationwide rabies data in people and animals during the past 81 years, from 1938 to 2018. For a variety of reasons, rabid bats are now the major source of human rabies in the United States.  Rabid bats have been reported from every state except Hawaii.  While the majority of bats in the wild do not carry rabies, you cannot tell which bats have rabies just by looking at them.  We also know people may not be aware that bats can spread rabies.  For example, we have had several large groups of people exposed to bats in university dorms, camping lodges, and schools.  People were not aware that they should be concerned about rabies.  In other instances we have heard of people catching and handling bats in parks or in their yards.  We are particularly concerned about these kinds of situations because if people don’t know about the risk of rabies they may not go to the doctor to see if they need PEP.  If people are exposed to rabies but do not get PEP prior to symptoms starting the disease is nearly always fatal.  Now, I want to emphasize that bats play a critical role in our environment.  So we don’t advocate killing bats, but we do want people to be careful.  Simply leaving them alone is the best way to reduce your risk of rabies.  We also have resources on our website about what to do if there’s a bat in your home.  It is crucial to vaccinate pets since dogs and cats can still get rabies from wildlife.  I would also like to highlight that since the 1990s we’ve had three times more rabid cats reported in the United States than rabid dogs.  Most people in the United States vaccinate their dog, but oftentimes people don’t vaccinate cats.  Vaccinating cats is very important in case they have contact with wildlife inside or outside the home.  Dr. Schuchat mentions that we have between one and three human rabies cases a year in the United States.  Around the world, though, there are nearly 60,000 deaths each year, most due to bites from rabid dogs.  Unfortunately, if people don’t receive PEP before rabies symptoms start, the disease is nearly always fatal.  That’s why we encourage people to see a health care provider right away if they have been bitten or scratched.  The provider can help determine if someone needs PEP. I want to clarify that not everyone who gets PEP for an animal bite was bitten by an animal that was rabid.  But oftentimes it’s not possible to catch and test an animal or to quarantine it and watch for symptoms.  So the safest course of action is to give PEP so we are sure the person is protected.  If the person was in fact exposed to rabies and they don’t get PEP, they will die.  It’s just too risky to take that chance.  People can protect themselves from rabies by leaving wildlife alone.  If you get bitten or scratched, wash the wound immediately with soap and water and see a health care provider.  Any direct contact with a bat, even if you don’t think you have been bitten, should be discussed with your health care provider to see if you need PEP.  PEP is extremely effective, but it needs to be started quickly.  You should also vaccinate your pets every year to protect yourself and your family.  If you find injured wildlife in your yard or home, don’t touch it.  You should call the appropriate authorities rather than trying to catch it or care for it yourself.  CDC has a list of contacts by state on our website, and they can provide advice on what to do in your area.  Health care providers have a role to play too.  They can ask their patients if they have had any recent animal bites or scratches or contact with bats.  If the answer is yes, assess whether they need PEP.  State and local health departments have tools to help health care providers if they have questions.  International travelers need to be aware that dogs at their destination may carry rabies.  Unlike in the United States, dogs in many countries are not vaccinated against rabies and can give the disease to people through bites or scratches.  So avoid contact with dogs while traveling and seek medical care as soon as possible if you are bitten or scratched.  Depending upon where the traveler is going, a health care provider may recommend the traveler get rabies vaccine before leaving.  Tremendous effort goes into providing comprehensive rabies prevention and control in the United States.  CDC collaborates with the U.S. Department of Agriculture, state and local health departments, health care providers, and veterinarians, who all play a role in keeping rabies deaths low in the U.S.  We remain committed to our work to keep pushing rabies back and helping people to understand how they can keep themselves, their families, and their communities safe from rabies.  I’d like to turn it back over to the moderator at this point.

KATHY HARBEN:  Thank you, Dr. Pieracci.  Victor, we are now ready for questions.

OPERATOR:  Thank you.  We will now begin the question and answer session.  To ask a question from the phone lines please press star 1, ensure your phone is unmuted, and record your name when prompted.  To withdraw your question press star 2.  One moment, please, for incoming questions.  Our first question comes from Jonathan Serrie.  Your line is open.

JONATHAN SERRIE/FOX NEWS: Thanks so much for taking my question.  This question is probably for Dr. Schuchat.  I’m wondering about the timing of this report.  Is there a specific case that prompted this “Vital Signs”  report, or is it a case where you looked at the numbers and said you know, bats are displaying a disproportionate role in human rabies, maybe people don’t realize the risk that bats can carry the virus, let’s warn them?

DR. ANNE SCHUCHAT: Thanks for that question. You know, bats have beaten out other wildlife now for the first time. So that was one of the motivations for the report.  But we also were aware that the summer’s coming and we have had these episodes of summer camps or cabins and some of the increased outdoor exposures that people have.  So we thought that this was a good time of year for us to issue the report.

KATHY HARBEN: Next question, please.

OPERATOR: Our next question comes from Mike Stobbe.  Your line is open.

MIKE STOBBE/AP: Hi.  Thank you for taking my question.  I’d like to ask a couple if i could; the first follows the earlier question.  So is there a seasonality to reports of people going to the ER with possible exposure?  Do most of those reports tend to happen in the summer?  Can you break that down?  Also, i was wondering regarding PEP you all say it’s extremely effective.  But is it always effective?  Has there ever been a case where someone got PEP on time but they still died?  And then the third question, if you all could talk a little about why you think bats surpassed raccoons?  What’s going on?  Is there more spread among bats or was there a success among the raccoon population, any other info on that.  Thank you.

DR. ANNE SCHUCHAT: Thanks so much, mike. Let me begin and then let Dr. Pieracci expand. We don’t have data about the seasonality for the post-exposure prophylaxis.  It’s something we can look at in the future, but we don’t have that today for you.  The issue with bats exceeding raccoons, there has been a very extensive effort led by the animal health sectors to control raccoon rabies, to keep it restricted to the east coast of the country.  It’s not that it just disappeared.  There was a big effort at wildlife vaccination to make that happen.  So let me let Dr. Pieracci go into a little bit more details about the effectiveness of post-exposure prophylaxis and the raccoon control efforts.

DR. EMILY PIERACCI: Thank you, Dr. Schuchat. So PEP is highly effective.  PEP is a series of vaccinations and injection of immunoglobulin that’s given to provide both short-term and long-range immunity for someone who’s been exposed to rabies.  The question about whether it is always effective and whether there have been reports of someone receiving PEP and then going on to develop rabies, the answer to that is yes.  There have been reports of people that were severely mauled by dogs that had injuries to their face or head that did not go to the hospital right away to begin PEP.  Rabies is a virus that travels through your nervous system.  And when you are injured in a location on your body such as your head or face or your hands, which are highly innervated, the virus can move quite quickly into your central nervous system and your brain.  And so one of the reasons we recommend that people get vaccination as soon as possible is to prevent that from happening.  So the cases, again, that we see where people have started PEP is usually because they were severely injured and did not start PEP soon enough, unfortunately.  To answer the question about bats surpassing raccoons, the U.S. Department of Agriculture has done an outstanding job with vaccinating our raccoon population on the east coast to prevent the westward spread of rabies into wildlife.  And so that is one of the reasons that we are seeing fewer cases in raccoons, we believe.  The increased cases — increased number of bats that are positive is also possibly a reflection of the increased contact that the public is having with wildlife.  Bats that are tested are generally bats that have had contact with people that we suspect may have rabies.  And as our urban landscape changes and more wildlife have to co-habitate with people, we’re having increased instances of people having contact with bats, which can then lead to the bats needing to be tested to see if they have rabies.

KATHY HARBEN: Next question, please.

OPERATOR: Our next question comes from James Gorman.  Your line is open.

JAMES GORMAN/ NEW YORK TIMES: Hi.  Thanks very much. A couple questions.  One, the bat population has been going way down because of white nose.  So is it — is that a surprise that they’re — how do you factor that in?  Another one is I just wanted to double-check.  You said 2015 was when the bats first surpassed raccoons.  So i was wondering why the — did those numbers just come to your attention and is that why you’re having this now?  And finally, in terms of cases reported to the CDC, the last one i could find online was in 2017, which was a woman bitten in India.  Have there been in 2018 and ’19 cases of human rabies that have been reported?  Thanks.

DR. ANNE SCHUCHAT: Thanks. Let me begin and then let Dr. Pieracci give you some more details. The timing of our report is not based on that 2015 transition.  The timing was based on the more extensive surveillance report that went through 19 — through 2018.  You know, the 81 years of data.  The bats surpassing happened, as i mentioned, began in 2015.  The issues about more recent cases, let me let Dr. Pieracci expand about.

DR. EMILY PIERACCI: So i want to make sure all of your questions. You may have to repeat a couple of them.  Sorry about that.  So you’re right.  2015 was the first year that we noticed that bats were surpassing raccoons in terms of the number of rabid animals in the United States.  What we’ve seen since 2015 and what prompted us to issue this “Vital Signs” report was this increase that we’re seeing in what we call mass bat exposures.  Those are instances where we have ten or more people that are exposed to a potentially rabid bat.  So as i mentioned earlier, we’ve got a lot of cases that we’ve been involved in where people are at campgrounds, in sorority houses, where bats are living in the attics, living in the homes, and no one is concerned about rabies.  And so as we see this increase with mass bat exposures we thought it would be a good time to try to raise awareness with the general public about the risk of rabies from wildlife.  Your question about the travel case back in 2017; that is the last confirmed case we have of a human who contracted rabies from a dog while traveling overseas.  However, one of the things that we noticed in this report is that this kind of seems to be an ongoing trend.  So we thought it would be a good idea to raise awareness for international travelers that dogs in many countries carry rabies.  And the way to protect yourself is to avoid contact with those dogs and to seek care immediately if you’re bitten or scratched by a dog while you’re traveling.  You had one question about white nose syndrome and the decreasing bat population.  So very limited studies have been done in terms of the percentage of bats in the wild that have rabies.  We believe that number is actually less than 1%.  But the difference is that the bats that we are testing are bats that have had contact with people.  And so while there’s an overall decrease in the bat population in the wild, there are still large numbers of bats that are living in urban environments, under bridges, in buildings, in the attics of people’s homes.  And so that’s why we’re seeing increased contact between people and bats.  I think that answers your question.

OPERATOR: Our next question comes from Robert Herriman/ Outbreak News Today.  Your line is open.

ROBERT HERRIMAN/ OUTBREAK NEWS TODAY: Hi.  Thank you for taking my questions.  The first one is the oral rabies vaccine bait has been useful in raccoon populations and other animals.  Is there anything available for bats?  And if not is there anything in the pipeline?  And my second question is concerning the cost of PEP.  I’ve seen ranges from a couple thousand dollars to more than $5,000.  Why the expense and can you explain the wide range of cost?  Thank you.

DR. ANNE SCHUCHAT: Thank you. Let me take the costs and let Dr. Pieracci talk about the other aspects of your question. You know, the price of drugs is a major priority for the Department of Health and Human Services and Secretary Azar has championed a number of efforts to look into that.  For products that are not widely used or for products that originated many years ago, there’s a lot of price variation.  And so we don’t control that here at the CDC but we did do the analysis of what the range of prices charged for the products were.  The immunoglobulin and rabies vaccines are products that are not necessarily in large supply, and there have been some interruptions in supply at times that have been a concern.  So a very important topic but not one that we have too much more to say about.  Dr. Pieracci, you want to answer the other aspect?

DR. EMILY PIERACCI: Sure. So your question about oral rabies vaccine bait, you are right. The U.S. Department of Agriculture has done an outstanding job with the oral rabies vaccination program in the United States and they have used it effectively in raccoon, fox, and even coyote populations in Texas.  The question you have about the vaccine for bats.  So there’s nothing currently available, but I will say that a number of universities and institutions are working on trying to develop a vaccine for bats.  It’s something that is definitely in the pipeline but just not available at this time.

KATHY HARBEN: Great.  We have time for one more question, please.

OPERATOR: Our final question comes from Alison Kutnitz.  Your line is open.

ALISON KUTNITZ/BOSTON GLOBE: Hi.  You mentioned raccoons and other animals being really confined to the east coast with rabies.  I was wondering if you could speak specifically to the New England area and any specific trends here or any concerns to be aware of.

DR. ANNE SCHUCHAT: The New England area looks pretty similar to the east coast in terms of the raccoon being the principal wildlife concern there. And then of course bats are all around the country except for in Hawaii.

KATHY HARBEN: Thanks very much.  Thank you to Dr. Schuchat and Dr. Pieracci for joining us today.  And thank you reporters for joining us as well.  If you have follow-up questions, you can e-mail us at media@cdc.gov or you can also call us at 404-639-3286.  This concludes our call.  Thank you.

OPERATOR: Thank you for your participation in today’s conference.  You may now disconnect.

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