Rabies, caused by a Lyssavirus, is a zoonotic disease with variable epidemiology throughout the United States, which poses unique control and management challenges for veterinarians. In West Virginia, approximately 90% of confirmed animal cases of rabies occur among wildlife, with most cases in raccoons, followed by skunks and bats. Among domestic animals, cats most commonly test positive for rabies.1 West Virginia's animal rabies data are consistent with national rabies surveillance data compiled by the CDC.2
Although multiple terrestrial rabies virus variants exist in the United States, RRVV is the only terrestrial rabies virus variant present in West Virginia. The epidemiology of rabies among raccoons in the state is interesting because RRVV is enzootic only in West Virginia's eastern and most northern counties (Figure 1). This distribution is, in part, determined by the Appalachian Mountains, which act as a natural barrier to raccoon movement.3 Additionally, West Virginia is part of the Appalachian Ridge Oral Rabies Vaccination Program, coordinated by the USDA APHIS Wildlife Services. Since 2001, millions of oral rabies vaccine baits have been distributed by air and ground throughout a zone in West Virginia, limiting the spread of RRVV westward across the state.
Map illustrating counties in West Virginia where RRVV is (gray areas) or is not (white areas) enzootic, on the basis of data available from 2006 to 2010.
Citation: Journal of the American Veterinary Medical Association 243, 1; 10.2460/javma.243.1.63
Veterinarians have a key role in rabies control efforts by providing regular vaccinations to their clients' animals. Additionally, veterinarians have responsibility for detecting and preventing further transmission of rabies from any infected animal to other animals and persons, including minimizing exposures to veterinary staff. Use of PPE and rabies preexposure prophylaxis is essential to providing protection against rabies to veterinary personnel.
The ACIP periodically publishes its recommendations for prevention of rabies in humans, which categorize persons into 4 risk groups on the basis of the frequency of exposure (continuous, frequent, infrequent, and rare) one might have to the rabies virus.4 In areas where terrestrial rabies is enzootic, veterinarians and staff are placed in the frequent risk category; the ACIP recommends that these persons receive preexposure vaccination (a 3-dose series administered on days 0, 7, and 21 or 28) and undergo serum RVNA titer assessments every 2 years (with or without a booster vaccination, depending on titer) to ensure adequate protection.4 In areas where terrestrial rabies is not enzootic, veterinarians and veterinary students are placed in the infrequent risk category; the ACIP recommends that these persons receive only the primary vaccination series. Preexposure rabies vaccination eliminates the need for administration of human rabies immune globulin and decreases the number of postexposure vaccine doses required by humans who subsequently are exposed to rabies. In addition to the ACIP recommendations, NASPHV developed the Veterinary Standard Precautions Compendium, which endorses the ACIP's rabies vaccination recommendations for veterinary personnel.5
Similar to West Virginia, other states often have distinct areas of terrestrial rabies enzooticity. On the basis of the increased risk for rabies in these areas and the importance of prevention efforts by veterinarians, the authors believe that rabies prevention policies in place in veterinary facilities might be more robust in areas where rabies virus is enzootic, compared with those in place in veterinary facilities in nonenzootic areas. The purpose of the study reported here was to assess the knowledge, attitudes, and practices of West Virginia veterinary facility owners regarding preexposure prophylaxis, including a comparison of data from facilities in counties where RRVV is enzootic with data from facilities in counties where RRVV is not enzootic.
Materials and Methods
Study design—From January through September 2011, a cross-sectional survey was conducted to assess the knowledge, attitudes, and practices of West Virginia veterinarians regarding rabies and preexposure prophylaxis. Owners of veterinary facilities licensed for 2011 by the West Virginia Board of Veterinary Medicine were eligible to participate in the study. Facility owners were contacted by staff from the West Virginia Division of Infectious Disease Epidemiology and asked to complete a questionnaire by telephone; if the owner agreed, the questionnaire was completed during that same telephone conversation. If a veterinarian owned > 1 facility, a questionnaire was completed for each facility. If > 1 veterinarian owned a facility, any 1 owner was allowed to complete the questionnaire.
The questionnaire comprised 4 sections. The first section was designed to collect information on the type of practice (small or companion animal, large or food animal, mixed, equine, or emergency), the county in which the facility was located, and the number of veterinarians and other staff employed by the facility. The second section involved open-ended questions about rabies, the epidemiology of animal rabies in West Virginia, and preexposure prophylaxis recommendations for veterinarians. The third section was designed to gauge each veterinarian's level of agreement with the position that rabies is an occupational concern. In this section, information was obtained regarding 4 types of veterinary staff (veterinarians, technicians and assistants, other staff, and volunteers) and responses to questions were recorded on a 5-point Likert scale (ranging from strongly agree to strongly disagree). Lastly, in the fourth section, questions for which the answer was yes or no were asked about facility policies and practices regarding preexposure prophylaxis for staff, compensation for employee vaccination, stray animal housing, preparation of specimens for rabies testing, and access to guidance for veterinarians regarding preexposure prophylaxis. The survey concluded with an open-ended question asking respondents for any additional comments.
Statistical analysis—Data were entered and analyzed with statistical software.a Facilities were considered to be in a county where RRVV is enzootic if at least 1 confirmed case of RRVV infection in an animal in that county had been reported within the previous 5 years (2006 to 2010)b; those facilities and counties were assigned an RRVV+ status. Facilities were considered to be in a county where RRVV is not enzootic if no confirmed cases of RRVV in an animal in that county had been reported within the same period; those facilities and counties were assigned an RRVV- status. Responses from veterinarians who owned facilities in RRVV+ counties were compared with responses from veterinarians who owned facilities in RRVV- counties via the Pearson χ2 test (when expected cell counts were ≤ 5, a Fisher exact test was used). A value of P ≤ 0.05 was considered significant. Prevalence ratios and 95% CIs were calculated to quantify the strength of an association.
Results
Of the 162 veterinary facilities licensed by the West Virginia Board of Veterinary Medicine for 2011, surveys were completed for 124 (77% response rate). All respondents were veterinarians who owned private facilities. Of 124 respondents, 88 (71%) owned small and companion animal practices and 34 (27%) owned mixed practices; equine (1/124) and emergency (1/124) facility owners each comprised 1% of total respondents. The number of veterinarians per facility ranged from 1 to 7 (mean, 2). The number of additional staff ranged from 0 to 32 (mean, 8). Sixty-four (52%) respondents owned facilities in RRVV+ counties, and 60 (48%) respondents owned facilities in RRVV- counties.
When asked what animal species in West Virginia were most frequently determined to be positive for rabies, raccoon (n = 113 respondents), skunk (57), and bat (31) were most commonly reported by the veterinary facility owners. Approximately half (66/124 [53%]) of facility owners knew whether the Oral Rabies Vaccination Program had been implemented in their county. Seventy-one of 124 (57%) respondents reported that preexposure prophylaxis involved administration of 3 injections of vaccine. Nearly all (118/124 [95%]) respondents reported that veterinarians should have their serum RVNA titers assessed after preexposure prophylaxis had been completed; however, less than one-third (33/124 [27%]) of respondents reported that those titers should be assessed every 2 years. No significant differences were noted between those responses from owners in RRVV+ counties and responses from owners in RRVV- counties.
Ninety-seven of 124 (78%) veterinary facility owners rarely (≤ 5 times/y) considered rabies as a differential diagnosis for animals examined in their practice. However, 19 of 64 (30%) veterinary facility owners in RRVV+ counties considered rabies as a differential diagnosis more frequently (> 6 times/y), compared with 4 of 60 (7%) veterinary facility owners in RRVV- counties (prevalence ratio, 4.3; 95% CI, 1.6 to 11.8; P < 0.01). Forty-nine of 64 (77%) veterinary facility owners practicing in RRVV+ counties were aware of their county's RRVV status, compared with 25 of 60 (42%) veterinary facility owners practicing in RRVV- counties (prevalence ratio, 1.8; 95% CI, 1.3 to 2.6; P < 0.01).
All veterinary facility owners (124/124 [100%]) agreed or strongly agreed that rabies is an occupational concern for veterinary staff, and most facility owners agreed or strongly agreed that veterinarians (122/124 [98%]) and technicians and assistants (111/124 [90%]) should receive preexposure prophylaxis. Fewer facility owners agreed or strongly agreed that other staff (85/124 [69%]) and volunteers (62/124 [50%]) with consistent animal contact should receive preexposure prophylaxis. Only 26 of 124 (21%) facility owners reported having a preexposure prophylaxis policy in place; however, 20 of 64 (31%) owners of facilities in RRVV+ counties reported having a policy, compared with only 6 of 60 (10%) owners of facilities in RRVV- counties (prevalence ratio, 3.1; 95% CI, 1.3 to 7.2; P < 0.01).
Fifty-six of 124 (45%) facility owners reported that veterinarians working in their establishment were required to receive rabies preexposure prophylaxis (Table 1); however, 115 of 124 (93%) facility owners reported that all veterinarians in the practice had completed a preexposure prophylaxis vaccination series. Assessment of veterinarians' serum RVNA titers was required at only 25 of 124 (20%) facilities, although 30 of 124 (24%) facility owners reported that all veterinarians in the practice had completed a titer assessment within the previous 2 years. Rabies preexposure prophylaxis policies were not commonly applied to veterinary technicians and assistants; only 19 of 124 (15%) facility owners required technicians and assistants to be vaccinated, and 36 of 124 (29%) facility owners reported that all technicians had completed their preexposure prophylaxis vaccination series. Serum RVNA titer assessments were required for technicians and assistants at 9 of 124 (7%) veterinary facilities; at 13 of 124 (10%) facilities, technicians and assistants had completed such a titer assessment within the previous 2 years. Among veterinary facility owners who employed other staff who had direct animal contact, only 10 of 61 (16%) required preexposure prophylaxis for those employees. Volunteers were largely not covered by preexposure prophylaxis policies mainly because only 25 of 124 (20%) facilities reported having volunteers, and only 1 of those 25 (4%) facilities required that volunteers receive preexposure prophylaxis. These policies at facilities in RRVV+ counties and at those in RRVV- counties were compared; among the 4 types of veterinary staff, significant differences were noted only for policies that applied to technicians and assistants.
Comparison of preexposure prophylaxis policies with regard to veterinarians, technicians, and assistants of 124 veterinary facilities in counties in West Virginia where RRVV is (RRVV+; n = 64) or is not (RRVV-; 60) enzootic based on data obtained in a telephone survey involving facility owners (1 owner respondent/facility).
| Variable | No. of facilities in RRVV+ counties (%) | No. of facilities in RRVV-counties (%) | Total No. of facilities (%) | Prevalence ratio* (95% Cl) | P value |
|---|---|---|---|---|---|
| Facility veterinarians | |||||
| Preexposure prophylaxis required for all veterinarians | 33 (52) | 23 (38) | 56 (45) | 1.3 (0.9–2.0) | 0.1 |
| Preexposure prophylaxis completed by all veterinarians | 59 (92) | 56 (93) | 115 (93) | 1.0 (0.9–1.1) | 0.8 |
| Titer assessments† required for all veterinarians | 16 (25) | 9 (15) | 25 (20) | 1.7 (0.8–3.5) | 0.2 |
| Titer assessments† completed by all veterinarians | 16 (25) | 14 (23) | 30 (24) | 1.1 (0.6–2.0) | 0.8 |
| Facility technicians and assistants‡ | |||||
| Preexposure prophylaxis required for all technicians and assistants | 15 (24) | 4 (7) | 19 (15) | 3.6 (1.3–10.2) | < 0.01 |
| Preexposure prophylaxis completed by all technicians and assistants | 27 (43) | 9 (15) | 36 (29) | 2.9 (1.5–5.6) | < 0.001 |
| Titer assessments† required for all technicians and assistants | 9 (15) | 0 | 9 (7) | 0 (undefined) | < 0.01 |
| Titer assessments† completed by all technicians and assistants | 11 (18) | 2 (3) | 13 (10) | 5.2 (1.2–22.7) | < 0.05 |
*Denominator for prevalence ratios include responses of no or don't know.
†Assessments to determine serum RVNA antibody titers.
‡Excludes 1 veterinary facility owner who did not employ any technicians or assistants.
Approximately half (57/124 [46%]) of facility owners covered the cost of rabies preexposure prophylaxis for employees, whereas 100 of 124 (81%) owners covered the cost (either out of pocket or through worker's compensation) of rabies PEP for employees. Among the 25 facility owners who reported having volunteers, 4 (16%) covered the cost of preexposure prophylaxis; however, 16 (64%) covered the cost of rabies PEP for volunteers.
Less than 30% of veterinary facility owners reported having a copy of or online access to the ACIP's preexposure prophylaxis recommendations for veterinarians or the NASPHV Veterinary Standard Precautions Compendium. However, facilities in RRVV+ counties were more likely to have a copy of or access to the compendium, compared with facilities in RRVV- counties (prevalence ratio, 2.0; 95% CI, 1.1 to 3.8; P < 0.05).
A total of 109 of 124 (88%) respondents had assisted their local health department by preparing and submitting animal specimens to the West Virginia Office of Laboratory Services for rabies testing. Vaccination policies for veterinarians and staff were not significantly different at veterinary facilities that prepared specimens for testing and at those that did not (data not shown). Forty-five of 124 (36%) facility owners reported housing stray animals for adoption or animal control purposes. No significant differences were noted between those responses from owners in RRVV+ counties and responses from owners in RRVV- counties.
Of the 80 comments provided by veterinary facility owners at the end of the survey, rabies preexposure prophylaxis cost concerns were reported most frequently (28 [35%]). Other concerns mentioned included the investment in vaccination in relation to staff turnover, difficulty in locating a health provider to administer the vaccine, and confusion regarding assessments of animal rabies exposures.
Discussion
Veterinarians who owned practices in West Virginia were generally knowledgeable of rabies epidemiology in that state.1 Almost all veterinary facility owners agreed that rabies was an occupational concern for veterinary staff and that veterinarians and technicians and assistants should receive preexposure prophylaxis. However, most owners did not have a rabies preexposure prophylaxis policy in place at their facility, and except for veterinarians (who typically completed the vaccination series during veterinary school), other veterinary staff did not commonly receive preexposure prophylaxis or regular assessments of serum RVNA titers.
Compared with owners of veterinary facilities in RRVV- counties, owners of veterinary facilities in RRVV+ counties were more likely to consider rabies as a differential diagnosis, be aware of the RRVV status of their county, have a rabies preexposure prophylaxis policy in place, have access to the NASPHV Veterinary Standard Precautions Compendium, and require that technicians and assistants receive preexposure prophylaxis and serum RVNA assessments. The proportions of facility owners in RRVV+ counties and RRVV- counties who had requirements for technicians and assistants to undergo preexposure prophylaxis or have regular RVNA titer assessments and who reported completion of preexposure prophylaxis or titer assessments by all technicians and assistants differed significantly; technicians and assistants were the only type of veterinary staff for whom these policy differences were noted.
One limitation of this study was that responses from owners of small animal veterinary facilities might be overrepresented. Additionally, only facility owners were surveyed; input from associate veterinarians might have provided additional insight. Possibly, the increased awareness observed among facility owners regarding rabies concerns in RRVV+ counties, compared with the level of awareness among facility owners in RRVV- counties, was a result of previous rabies exposures in those facilities, rather than inherently greater knowledge regarding rabies.
The rabies vaccination rates among veterinarians (93%) and technicians and assistants (29%) determined in the present study were consistent with findings of previous studies.6–8 In Sonoma County, Calif, a survey revealed that the rabies vaccination rate among veterinarians was 85%, compared with a vaccination rate of 18% among other staff.6 Another survey in North Carolina found a vaccination rate of 87% among veterinarians.7 Additionally, a national survey of AVMA members revealed that vaccination rates for veterinarians ranged from 94% to 97%, but < 25% of those vaccinated had completed an assessment of their serum RVNA titers within the previous 2 years.8 These study results indicate a consistently high rate of initial vaccination among veterinarians; however, vaccination of other staff and titer assessments to ensure continued protection are infrequently reported.
As in West Virginia, other states have specific areas of rabies enzooticity, regardless of the terrestrial rabies virus variant in those locations.2 The present study appears to be the first to compare policies at veterinary facilities in terrestrial rabies-enzootic areas with policies at veterinary facilities in which terrestrial rabies is not enzootic. The finding that owners of facilities in RRVV+ counties in the present study, where exposures are likely to occur, appear to have a comprehensive approach to rabies control is encouraging. However, of concern is that preexposure prophylaxis policies were not commonly applied to technicians and assistants, even in RRVV+ areas.
Preexposure prophylaxis is an important part of protecting veterinary staff from rabies virus infection, but implementation of additional infection control measures should also be emphasized. Such measures include appropriate use of equipment and facilities to limit rabies virus exposures, training of staff in animal handling and restraint techniques, and use of PPE. However, a national survey of infection control practices of AVMA members found that 70% of small animal veterinarians and 32% of large animal veterinarians who were concerned about rabies did not use recommended PPE during examination of an animal with neurologic signs.8 These findings further emphasize the importance of preexposure prophylaxis for veterinary staff, given that other preventive measures may not always be in place.
On the basis, in part, of the findings of the national survey of infection control practices of AVMA members,8 the Veterinary Standard Precautions Compendium was first developed by NASPHV in 2006. Despite the fact that this guidance has been available for years, > 70% of West Virginia veterinary facilities did not have copies of the compendium available for use in the present study. Although this study did not assess PPE use in West Virginia practices, it is likely that PPE use among West Virginia veterinarians is similar to that among veterinarians in the rest of the country.
The authors encourage all veterinary practices to consider revising or implementing a rabies policy on the basis of ACIP recommendations. The cost of rabies preexposure prophylaxis is prohibitive for certain veterinary facilities to provide to staff, and this concern is recognized. One approach to minimizing vaccine cost and availability challenges is for state veterinary associations to collaborate with their local and state public health partners. Rabies vaccination clinics or assessments of serum RVNA titers are offered at particular state veterinary medical association meetings as well as at the AVMA annual convention. Although veterinarians might still need to pay for these services, having them available at meetings is a convenience for its members. Technicians and other staff are often not eligible for these services, however. Implementation of PEP is an urgent matter and requires considerable resources. Ensuring that veterinary staff are vaccinated will minimize the financial burden and public health response, if a rabies exposure occurs within a facility.
ABBREVIATIONS
| ACIP | Advisory Committee on Immunization Practices |
| CI | Confidence interval |
| NASPHV | National Association of State Public Health Veterinarians |
| PEP | Postexposure prophylaxis |
| PPE | Personal protective equipment |
| RRVV | Raccoon rabies virus variant |
| RVNA | Rabies virus neutralizing antibody |
Epi Info, version 7.0.8.0, CDC, Atlanta, Ga.
Blanton J, CDC, Atlanta, Ga: Personal communication, 2011.
References
1 West Virginia Department of Health and Human Resources, Office of Epidemiology and Prevention Services. West Virginia rabies surveillance data from 1999–2010. Available at: www.dhhr.wv.gov/oeps/disease/Zoonosis/Rabies/Documents/Rabies_Annual_Rep_2011.pdf. Accessed Jun 18, 2012.
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3 USDA APHIS Wildlife Services. Preventing the spread of raccoon rabies. Program aid No. 1933. National Rabies Management Program. Washington, DC: USDA, 2010. Available at: www.aphis.usda.gov/publications/wildlife_damage/content/printable_version/raccoon_rabies.pdf. Accessed Jun 18, 2012.
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