Rabies postexposure prophylaxis, New York, 1995-2000.
The epidemiology of human rabies rabies (rā`bēz, ră`–) or hydrophobia (hī'drəfō`bēə), acute viral infection of the central nervous system in dogs, foxes, raccoons, skunks, bats, and other animals, and in postexposure prophylaxis Postexposure prophylaxis (PEP)
Any treatment given after exposure to a disease to try to prevent the disease from occurring. In the case of rabies, PEP involves a series of vaccines given to an individual who has been bitten by an unknown animal or one that is (PEP) in 4 upstate New York Upstate New York is the region of New York State north of the core of the New York metropolitan area. It has a population of 7,121,911 out of New York State's total 18,976,457. Were it an independent state, it would be ranked 13th by population. counties was described from data obtained from 2,216 incidences of PEP recorded by local health departments from 1995 to 2000. Overall annual incidence for the study period was 27 cases per 100,000 persons. Mean annual PEP incidence rates were highest in rural counties and during the summer months. PEP incidence was highest among patients 5-9 and 30-34 years of age. Bites accounted for most PEP (51%) and were primarily associated with cats and dogs Cats and Dogs
A slang term referring to speculative stocks that have short or suspicious histories for sales, earnings, dividends, etc.
In a bull market analysts will often mention that everything is going up, even the cats and dogs. . Bats accounted for 30% of exposures, more than any other group of animals; consequently, bats have replaced raccoons as the leading rabies exposure source to humans in this area.
Combined with effective human rabies prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine , canine rabies control programs were responsible for the steady decline of human rabies in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. , from 20-25 annual cases in the 1940s to <3 annual cases in the 1990s (1-4). Although the current incidence of human rabies in the United States is negligible compared to that of other infectious diseases infectious diseases: see communicable diseases. , the number of persons seeking rabies postexposure prophylaxis (PEP) is high; 18,238 persons received PEP in New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of (excluding New York City New York City: see New York, city.
New York City
City (pop., 2000: 8,008,278), southeastern New York, at the mouth of the Hudson River. The largest city in the U.S. ) from 1993 to 1998 (5). No proven curative curative /cur·a·tive/ (kur´ah-tiv) tending to overcome disease and promote recovery.
1. Serving or tending to cure.
2. treatment has been documented for rabies once clinical disease begins (6). Human rabies can be prevented by following the Advisory Committee on Immunization Practices The Advisory Committee on Immunization Practices (ACIP) consists of fifteen advisors to the Centers for Disease Control and Prevention (CDC), selected by the Secretary of the United States Department of Health and Human Services, to provide advice and guidance on the most effective (ACIP ACIP Cardiology A clinical trial–Asymptomatic Cardiac Ischemia Pilot Study that evaluated 3 therapeutic strategies2 for ↓ myocardial ischemia during exercise testing. ) recommendations of local wound care and prompt administration of human rabies immune globulin rabies immune globulin
Specific immune globulin from human donors immunized against rabies. (HRIG HRIG Human Rabies Immune Globulin , 20 IU/kg) on day 0 and vaccine on days 0, 3, 7, 14, and 28 (7). For persons who have been previously vaccinated, the recommended prophylaxis consists of a vaccine dose on days 0 and 3.
Studies addressing rabies PEP incidence indicate a rising trend since the 1970s. Estimates of annual PEP incidence in Georgia increased from 1.94 cases/100,000 in 1970 to an estimated 6.17 cases/100,000 from 1995 to 2001 (1, S.J. Onufrak, Source-specific risks among patients receiving rabies post-exposure prophylaxis Post-exposure prophylaxis (PEP) is any prophylactic treatment started immediately after exposure to a disease (such as a disease-causing virus), in order to prevent the disease from breaking out. in Georgia [master's thesis]. Atlanta: Emory University Emory University (ĕm`ərē), near Atlanta, Ga.; coeducational; United Methodist; chartered as Emory College 1836, opened 1837 at Oxford. It became Emory Univ. in 1915 and in 1919 moved to Atlanta. ; 2003). At the national level, incidence was most recently estimated at 8.69 cases/100,000 in 1980 (8). Increases are probably attributable to an expanding raccoon raccoon, nocturnal New World mammal of the genus Procyon. The common raccoon of North America, Procyon lotor, also called coon, is found from S Canada to South America, except in parts of the Rocky Mts. and in deserts. rabies epizootic ep·i·zo·ot·ic
Affecting a large number of animals at the same time within a particular region or geographic area. Used of a disease.
ep in the mid-Atlantic states Mid-At·lan·tic States
See Middle Atlantic States.
Noun 1. Mid-Atlantic states - a region of the eastern United States comprising New York and New Jersey and Pennsylvania and Delaware and Maryland
U.S.A. and changes in PEP consideration after potential bat exposure (5). We describe demographic and animal exposure data associated with PEP in upstate New York several years after the establishment of the raccoon rabies variant and compare them with 1993-1994 data from the same area (9).
Monroe and Onondaga Counties encompass the cities of Rochester and Syracuse and are predominantly urban-suburban with population densities of 422 and 232 persons/[km.sup.2], respectively. Cayuga and Wayne Counties Wayne County is the name of sixteen counties in the United States of America, some named for the American Revolutionary War general Anthony Wayne:
We considered all PEP cases recorded on standardized standardized
pertaining to data that have been submitted to standardization procedures.
standardized morbidity rate
see morbidity rate.
standardized mortality rate
see mortality rate. reports by the 4 local health departments from 1995 to 2000. Data included patient demographics, animal characteristics, and exposure details. The report form was changed in 1998, with the addition of age, sex, treatment dates, and more detailed exposure information for bat-related PEE Age and sex data were obtained directly from local health departments for PEP cases before 1998.
Exposure source was defined as the suspected or confirmed rabid animal that directly or indirectly resulted in potential human exposure. Direct exposure consisted of a bite, scratch, or contamination of mucous membrane mucous membrane
A membrane lining all body passages that communicate with the exterior, such as the respiratory, genitourinary, and alimentary tracts, and having cells and associated glands that secrete mucus. Also called mucosa. with potentially infectious material directly from a suspected rabid animal. Indirect exposure consisted of contact with potentially contaminated contaminated,
v 1. made radioactive by the addition of small quantities of radioactive material.
2. made contaminated by adding infective or radiographic materials.
3. an infective surface or object. fomites fomites
see fomes. (e.g., saliva from a pet's fur that comes into contact with open wounds or mucous membranes Mucous membranes
The inner tissue that covers or lines body cavities or canals open to the outside, such as nose and mouth. These membranes secrete mucus and absorb water and salts.
Mentioned in: Leprosy, Pulmonary Fibrosis, Topical Anesthesia ). Cases that lacked specific information about route of exposure were classified as unspecified. Cryptic cryp·tic
1. Hidden or concealed.
2. Tending to conceal or camouflage, as the coloring of an animal. or unspecified bat exposures consisted of discovering a bat in a room with a sleeping person, unattended child, mentally impaired person, intoxicated in·tox·i·cate
v. in·tox·i·cat·ed, in·tox·i·cat·ing, in·tox·i·cates
1. To stupefy or excite by the action of a chemical substance such as alcohol.
2. person, or someone otherwise unable to rule out contact. Rabies diagnostic results were obtained on animal cases from the New York State Department of Health Wadsworth Center Rabies Laboratory. Population data from the 2000 US census were used to calculate the incidence of PEP by county, age, and sex (10). Statistical analyses, including frequencies and chi-square tests chi-square test: see statistics. , were performed with the SAS (1) (SAS Institute Inc., Cary, NC, www.sas.com) A software company that specializes in data warehousing and decision support software based on the SAS System. Founded in 1976, SAS is one of the world's largest privately held software companies. See SAS System. statistical package version 8.0 (SAS Institute SAS Institute Inc., headquartered in Cary, North Carolina, USA, has been a major producer of software since it was founded in 1976 by Anthony Barr, James Goodnight, John Sall and Jane Helwig. Inc., Cary, NC, USA).
A total of 2,216 PEP cases were reported from the study area from 1995 to 2000, with 317-469 cases each year. Annual PEP incidence was 23-34 cases/100,000 during the 6-year period (average 27/100,000). The mean annual incidence for the urban counties of Monroe and Onondaga (319 residents/[km.sup.2]) was 23 cases/100,000 compared to 56 cases/100,000 in the rural counties of Cayuga and Wayne (52 residents/[km.sup.2]). No failures of PEP were recorded.
PEP cases tended to increase in the late spring/early summer; the highest number of PEP cases was seen in August/September in 1996 and 1997 and in July/August from 1998 to 2000 (Figure 1). Of 2,109 (95%) PEP cases for which sex data were available, 51% were male. The median age of PEP recipients was 27 years for men and 29 years for women. The mean annual incidence of PEP for men was 26 cases/100,000 and for women 24 cases/ 100,000. PEP incidence rates were highest in persons 5-9 years of age, followed by those 30-34 years of age (Figure 2). No significant differences among sex or age distributions and PEP were seen.
[FIGURES 1-2 OMITTED]
Wild animal exposures accounted for 1,081 PEP cases (49%), domestic animals accounted for 1,057 cases (48%), and species of exposure animal was not identified for 78 cases (3%) (Table 1). Bats accounted for 663 (61%) PEP cases related to wildlife exposures, while other sources of wildlife-related PEP included raccoons (250 cases), foxes (85 cases), skunks (46 cases), woodchucks (12 cases), opossums (6 cases), deer (5 cases), beavers, coyotes, and squirrels (3 cases each), and other wild species (5 cases). PEP from bat exposure was significantly associated with an urban setting (p<0.001). Among domestic animal exposures that resulted in PEP, 523 were attributed to cats, 498 to dogs, 19 to cattle, 11 to horses, 4 to ferrets, and 1 each to a pet rabbit and monkey.
Animals were not available for observation or testing for 66% of rabies PEP cases that resulted from exposure to cats and 89% that resulted from exposures to dogs. Of the dog-associated PEP, significantly (p<0.001) more of them (93%) occurred in urban counties compared to rural counties (Table 2). During the study period, only 16 (3%) dog-associated PEP cases involved dogs that were tested for rabies, and none were confirmed rabid. Among cats, 132 (25%) cat-associated PEP cases involved cats that were tested for rabies; of these, 110 PEP cases (83%) involved exposure to a confirmed rabid cat.
A total of 1,128 (51%) PEP cases were attributed to animal bite; 670 (30%) persons reported nonbite exposures, and 418 (19%) reported exposure as unknown or unspecified (Table 1). Among nonbite-associated PEP recipients, 69% reported direct animal contact. Of the 1,106 bite-related PEP recipients that reported the species, 78% involved domestic animals. In 62% of potential exposures to bats, an exposure route was not described.
Exposure of only 1 person to a suspected rabid animal precipitated 1,336 (60%) PEP cases (Table 3). Exposure of a single person was more likely to be associated with a bite (p<0.001). Wild animal species accounted for 72% of group exposure PEP. The largest group occurred in June 1999, when 29 persons received PEP after exposure to a rabid cat.
Laboratory diagnosis of rabies was sought in 249 animals associated with 515 PEP cases (23%). Contact with a wild animal accounted for 348 cases (68%) where laboratory diagnosis was sought. Raccoons accounted for 176 (57%) of 309 PEP cases attributed to confirmed rabid wildlife. Nonbite exposures accounted for 366 (73%) of 501 PEP cases in which a laboratory diagnosis of rabies was obtained. Laboratory diagnosis of rabies in the exposing animal was significantly associated with nonbite exposure (p<0.001).
From 1998 to 2000, the time of PEP initiation in relation to exposure was available for 1,219 (98%) of 1,248 cases. The period between exposure and treatment varied from 0 to 115 days with a median of 3 days. Among persons with bite exposure, 199 (38%) of 528 began PEP the same day as exposure, while 14% of persons who reported a nonbite exposure received treatment the same day as exposure (p<0.001). Medians of 1 day for wild animal exposures and 2 days for domestic animal exposures were associated with bite exposures and 3 and 6 days, respectively, for nonbite exposures.
Of 1,248 PEP cases reported from 1998 to 2000, administration of PEP biologics was recorded as complete and appropriate (e.g., HRIG was given if indicated and the person completed all 5 vaccinations) in 1,035 (83%) cases. A total of 62 persons (5%) had received prior vaccination; 47 (76%) completed the appropriate course of treatment. Among rabies vaccination-naive persons, 984 (85%) of 1,157 completed the appropriate course of treatment. Information regarding treatment scheduling was not available for 29 (2%) PEP cases.
Information on vaccine scheduling was available for 724 (58%) of the 1998-2000 PEP cases. Administration schedules were correct for 605 (84%) persons. Six persons (1%) did not receive HRIG when it was indicated, and 9 (1%) previously vaccinated persons received HRIG, although it was not indicated. One person received 6 total vaccine doses. Adverse events were listed as either present or absent with no scale as to severity. In all, 63 persons (5%) reported adverse reactions adverse reactions,
n.pl unfavorable reactions resulting from administration of a local anesthetic; responsible factors include the drug used, concentration, and route of administration. to vaccine or to HRIG.
Epidemiologic characteristics of possible rabies exposure leading to PEP changed substantially in this 4-county upstate New York area from 1993 to 2000. The major changes were the animal species exposure source and type of exposure (Table 4). From 1995 to 2000, overall PEP incidence declined in this area to 27 cases/100,000 from a high of 43 cases/100,000 in the early 1990s (9). Although affected by complex factors, this may reflect increased knowledge about what constitutes an exposure from terrestrial mammals among the public and healthcare providers and how to avoid exposures.
In agreement with other recent studies, cats accounted for a majority of the exposures from domestic animals (9). Reinforced emphasis of responsible pet ownership and routine vaccination with specific attention to the ideal of maintaining cats indoors Cats Indoors is a campaign by the American Bird Conservancy to encourage control of cats in order to protect birds from predation by cats. The objective of the Conservancy is that all domestic cats should be kept safely enclosed. and up-to-date on their rabies vaccinations may help to reverse this trend. At this time, many states and localities do not require rabies vaccination in cats. New York established a statewide requirement for rabies vaccination for cats in 2002. Progress in this area would be further enhanced through tangible enforcement mechanisms.
The passive nature of PEP data collection is an inherent weakness in most studies addressing PEP incidence. The capture rate in this study is high because New York has a requirement for reporting all PEP cases and provided partial reimbursement Reimbursement
Payment made to someone for out-of-pocket expenses has incurred. to local health departments for uncovered expenses. However, some cases may not have been reported if costs were borne by the private sector.
Potential exposures to bats have replaced raccoons as the most common species leading to PEP (Figure 3). By 1998, bats had become the leading source of exposure for which PEP was sought in this area. Historically, bats have only accounted for 5% to 10% of PEP cases (1,8,9). Furthermore, most exposures to bats (62%) were cryptic or listed as unknown; in other words Adv. 1. in other words - otherwise stated; "in other words, we are broke"
put differently , the exposure could not be described as a bite from a bat or as direct or indirect contamination of an open wound or mucous membrane with infectious material from a bat.
[FIGURE 3 OMITTED]
One hypothesis in the debate surrounding cryptic bat exposure and subsequent human rabies is that a bite from a bat is dismissed as insignificant or is unrecognized by the person because of somnolence somnolence /som·no·lence/ (som´no-lens) drowsiness or sleepiness, particularly in excess.
1. A state of drowsiness; sleepiness.
2. or other impairment. For example, 32 human rabies cases have been caused by bat rabies virus rabies virus
A rather large, bullet-shaped virus of the genus Lyssavirus that causes rabies. variants from 1980 to 2004, but only 5 patients reported a bite from a bat. However, a bat "encounter" was recalled in 75% of cases, sometimes by family members or associates. Moreover, bat bites do not typically require medical attention for trauma from the bite itself (Figure 4).
[FIGURE 4 OMITTED]
Recognizing a potential exposure by the patient and appropriate administration of PEP by healthcare professionals is critical to maintaining the low rates of human rabies deaths observed in the United States. Although the rate is low, the number of human rabies cases caused by bat-associated rabies virus variants rose from 2 during the 1980s to 20 during the 1990s. This apparent increase in bat-associated human rabies cases led to changes in the recommendations for PEP to be considered in situations where a bat is physically present, a bite cannot be ruled out, and rabies cannot be ruled out by testing the bat. This cautionary language was formalized for·mal·ize
tr.v. for·mal·ized, for·mal·iz·ing, for·mal·iz·es
1. To give a definite form or shape to.
a. To make formal.
b. in the 1999 update of ACIP recommendations for human rabies prevention and control (7). Although these recommendations have been criticized (11), they have been widely implemented in public health practice. In addition to the ACIP recommendations, the public health response in New York consisted of updated rabies guidelines and an education campaign on bats and rabies during the late 1990s (7,12,13). Though these guidelines may have increased PEP, informed decision-making should always be used to reduce unnecessary PEP.
Despite increased educational emphasis on bats and rabies, public knowledge about the risk of rabies exposure from bats is lacking (13,14). A New York study documented that only 17%-26% of respondents knew that bats found in homes should not be immediately released (before considering the need to test the bat) (13). Additionally, a Colorado study found that at least a third of human encounters with bats that result in a possible exposure could have been prevented by adopting a "do not touch" approach to wildlife (15).
The deaths in 1993, 1994, and 1995 of 3 young girls in New York, Washington, and Connecticut and the death of a New Jersey man in 1997 (16-19) caused by a bat rabies virus variant elicited mass media attention. Sudden increases in PEP after highly publicized pub·li·cize
tr.v. pub·li·cized, pub·li·ciz·ing, pub·li·ciz·es
To give publicity to.
Adj. 1. publicized - made known; especially made widely known
publicised rabies cases or exposures have been previously described (20,21). Local and national events that involve a potential rabies case may affect how persons and physicians assess the risk of an animal exposure, perhaps leading to use of PEP in an environment of heightened concern rather than in response to a true exposure (21,22).
The 1999 ACIP guidelines (currently in the nascent nascent /nas·cent/ (nas´ent) (na´sent)
1. being born; just coming into existence.
2. just liberated from a chemical combination, and hence more reactive because uncombined. stages of another update), as well as the availability of expert consultation at the local, state, and national level, should be widely promoted among healthcare professionals responsible for advising patients and providing PEP. Ultimately, public education about bats and rabies may increase the number of persons who seek PEP. A balanced approach is necessary to curtail inappropriate PEP and avoid unnecessary human deaths, such as the recent California case in which a patient did not seek PEP after a bat bite (23). Similarly, the recent Wisconsin human rabies case resulting from a bat bite was preventable had the risk been understood and had PEP been sought and appropriately administered. Survivorship survivorship n. the right to receive full title or ownership due to having survived another person. Survivorship is particularly applied to persons owning real property or other assets, such as bank accounts or stocks, in "joint tenancy. in this case provides a welcome but extremely rare exception to the paradigm of rabies as inevitably lethal (24). It does not alter the ultimate goal of absolute human rabies prevention.
We thank the public health professionals in the New York state public health system, including Hwa-Gan Chang, Barbara Wallace, Candace Noonan-Toly, and Yoichiro Hagiwara for maintenance of the rabies exposure reporting system; personnel from the 4 county health departments, specifically Lisa Jones, Nancy Bennett, Mary Anne Trupei, Linda Allen, Tam Cleveland, Diane Rothermel, Deb Dolan, and Lynn Crane; Charles Yrimarchi, Robert Rudd, and Richard Raczkowski for providing detailed diagnostic data; and Charles Rupprecht for his leadership and assistance in the editorial process of this paper.
This research was supported in part by both an appointment to the Research Participation Program at the Centers for Disease Control and Prevention Centers for Disease Control and Prevention (CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice.
CDC - Control Data Corporation ) administered by the Oak Ridge Institute for Science and Education The Oak Ridge Institute for Science and Education (ORISE) is a U.S. Department of Energy institute focusing on scientific initiatives to research health risks from occupational hazards, assess environmental cleanup, respond to radiation medical emergencies, support national and a grant from the CDC foundation.
All material published in Emerging Infectious Diseases An emerging infectious disease (EID) is an infectious disease whose incidence has increased in the past 20 years and threatens to increase in the near future. EIDs include diseases caused by a newly identified microorganism or newly identified strain of a known microorganism (e.g. is in the public domain and may be used and reprinted without special permission; proper citation, however, is required.
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in·tern or in·terne
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excludes the devil; used on door frames. [Medieval Folklore: Boland, 56]
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Bureau of the Census . American FactFinder [database on the Internet]. [cited 2003 Feb]. Available from http://factfinder.census.gov/home/ saff/main.html
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(14.) Gibbons Famous people named Gibbons include:
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n. 1. A second or new appearance; the act or state of appearing again.
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Jesse D. Blanton, * Nadine Y. Bowden, * Millicent Eidson, ([dagger]) Jeffrey D. Wyatt, ([double dagger double dagger
A reference mark () used in printing and writing. Also called diesis.
Noun 1. ]) and Cathleen A. Hanlon *
* Centers for Disease Control and Prevention, Atlanta, Georgia, USA; ([dagger]) New York State Department of Health, Albany, New York For other uses, see Albany.
Albany is the capital of the State of New York and the county seat of Albany County. Albany lies 136 miles (219 km) north of New York City, and slightly to the south of the juncture of the Mohawk and Hudson Rivers. , USA; and ([double dagger]) University of Rochester The University of Rochester (UR) is a private, coeducational and nonsectarian research university located in Rochester, New York. The university is one of 62 elected members of the Association of American Universities. School of Medicine & Dentistry dentistry, treatment and care of the teeth and associated oral structures. Dentistry is mainly concerned with tooth decay, disease of the supporting structures, such as the gums, and faulty positioning of the teeth. , Rochester, New York This article is about the city of Rochester in Monroe County. For the town in Ulster County, see Rochester, Ulster County, New York.
Rochester, once known as The Flour City, and more recently as The Flower City or , USA
Address for correspondence: Jesse Blanton, Viral and Rickettsial rickettsial /rick·ett·si·al/ (ri-ket´se-al) pertaining to or caused by rickettsiae.
Relating to, or caused by a member of the genus Rickettsia. Zoonoses Zoonoses
Infections of humans caused by the transmission of disease agents that naturally live in animals. People become infected when they unwittingly intrude into the life cycle of the disease agent and become unnatural hosts. Branch, Division of Viral and Rickettsial Diseases Noun 1. rickettsial disease - infectious disease caused by ticks or mites or body lice infected with rickettsial bacteria
infectious disease - a disease transmitted only by a specific kind of contact , Centers for Disease Control and Prevention, Mailstop G33, 1600 Clifton Rd, Atlanta, GA 30333, USA; fax: 404-639-1564; email: email@example.com
Mr Blanton is a research scientist in the Viral and Rickettsial Zoonoses Branch at the Centers for Disease Control and Prevention in Atlanta. His interests include the epidemiology of rabies and other zoonotic diseases Zoonotic diseases
Diseases caused by infectious agents that can be transmitted between (or are shared by) animals and humans. This can include transmission through the bite of an insect, such as a mosquito.
Mentioned in: West Nile Virus .
Table 1. Human rabies postexposure prophylaxis (PEP) by animal source, 4 counties, New York, 1995-2000 * Nonbite, n (%) Direct Saliva/NT Animal source Bite, n (%) Scratch ([dagger]) Raccoon 48 (19) 16 (6) 65 (26) Bat (all species) 115 (17) 29 (4) 100 (15) Other wild species ([paragraph]) 76 (45) 6 (4) 41 (24) All wild species 239 (22) 51 (5) 206 (19) Cat 367 (70) 64 (12) 89 (17) Dog 493 (99) 0 3 (1) Other domestic species (#) 7 (19) 0 28 (78) All domestic species 867 (82) 64 (6) 120 (11) Unknown 22 (28) 4 (5) 19 (24) Total 1,128 (51) 119 (5) 345 (16) Nonbite, n (%) Indirect ([double Unspecified Total, Animal source dagger]) ([section]) n (%) Raccoon 120 (48) 1 (<1) 250 (11) Bat (all species) 11 (2) 408 (62) 663 (30) Other wild species ([paragraph]) 44 (26) 1 (1) 168 (8) All wild species 175 (16) 410 (38) 1,081 (49) Cat 3 (1) 0 523 (24) Dog 0 2 (<1) 498 (22) Other domestic species (#) 0 1 (3) 36 (2) All domestic species 3 (<1) 3 (<1) 1,057 (48) Unknown 28 (36) 5 (7) 78 (3) Total 206 (9) 418 (19) 2,216 (100) * Data are from Cayuga, Monroe, Onondaga, and Wayne Counties. ([dagger]) Direct contamination of an open wound or mucous membrane with potentially infectious material such as saliva or neural tissue (NT). ([double dagger]) No known direct contact with a rabid or suspected rabid animal. Indirect exposure consisted of possible contact with saliva on an animal (i.e., pet dog or cat) or inanimate object from a suspected rabid animal that resulted in contamination of an open wound or mucous membrane. ([section]) Unspecified contact indicates no exposure information was listed or exposure was indicated as unknown on data records. Unspecified exposure for bats includes being in the physical presence of a bat and not being able to rule out direct contact, particularly a bite. More people received PEP after unspecified exposure to bats than any other group of animals (p<0.001). ([paragraph]) Includes beaver, coyote, chipmunk, deer, fox, mouse, opossum, otter, rat, skunk, squirrel, and woodchuck. (#) Includes cow, ferret, horse, monkey, and rabbit. Table 2. Human rabies postexposure prophylaxis (PEP) by setting, 4 counties, New York, 1995-2000 * Animal source Urban, n (%) Rural, n (%) Dog ([dagger]) 463 (92) 35 (7) Cat 386 (74) 137 (26) Other domestic ([double dagger]) 16 (44) 20 (56) All domestic 865 (82) 192 (18) Raccoon 162 (65) 88 (35) Bat ([section]) 456 (69) 207 (31) Fox 50 (69) 35 (41) Skunk 28 (61) 18 (39) Other wild ([paragraph]) 19 (51) 18 (49) All wild 715 (66) 366 (34) Total (#) 1,580 (74) 558 (26) Annual rate/100,000 22.6 56.9 * Rabies PEP cases reported to the health departments of 2 relatively urban counties, Onondaga and Monroe, and 2 relatively rural counties, Cayuga and Wayne. ([dagger]) Human PEP cases from dog exposures were significantly higher in urban counties (p<0.001). ([double dagger]) Other domestic animal exposures included 2 cows (10 cases), 3 ferrets (4 cases), 1 monkey (1 case), and 1 rabbit (1 case) in urban counties and 5 cows (9 cases) and 2 horses (11 cases) in rural counties. ([section]) Human PEP cases due to bat exposures were significantly higher in urban counties (p<0.001). ([paragraph]) Other wild animal exposures included 8 woodchucks (8 cases), 4 opossums (5 cases), 1 beaver (2 cases), 1 rat (1 case), 1 coyote (1 case), 1 mouse (1 case), and 1 otter (1 case) in urban counties and 5 deer (5 cases), 4 woodchucks (4 cases), 2 squirrels (3 cases), 2 coyotes (2 cases), 2 chipmunks (2 cases), 1 beaver (1 case), and 1 opossum (1 case) in rural counties. (#) 78 PEP cases excluded because animal source was missing. Table 3. Human rabies postexposure prophylaxis (PEP) by group size, 4 counties, New York, 1995-2000 Group size, n (%) Characteristics 1 2 3 No. 1,336 (60) 284 (13) 159 (7) No. sources 1,336 (83) 142 (9) 53 (3) Route of exposure * Bite ([dagger]) 1,008 (75) 69 (24) 18 (11) Nonbite 316 (24) 205 (72) 132 (83) Unknown 12 (1) 10 (4) 9 (6) Source of exposure * Dog or cat 845 (63) 50 (18) 27 (17) Other domestic species 5 (<1) 12 (4) 0 Raccoon 111 (8) 44 (16) 21 (13) Bat 241 (18) 132 (46) 96 (60) Other wild species 97 (7) 36 (13) 9 (6) Unknown source animal 37 (3) 10 (3) 6 (4) Mean age (y) 30.90 31.6 23.8 Group size, n (%) [greater than or Characteristics 4 5 equal to] 6 No. 192 (9) 55 (2) 190 (9) No. sources 48 (3) 11 (1) 18 (1) Route of exposure * Bite ([dagger]) 6 (3) 1 (2) 26 (14) Nonbite 170 (89) 49 (89) 163 (86) Unknown 16 (8) 5 (9) 1 (<1) Source of exposure * Dog or cat 4 (2) 5 (9) 90 (47) Other domestic species 4 (2) 0 15 (8) Raccoon 32 (17) 2 (4) 40 (21) Bat 147 (76) 43 (78) 4 (2) Other wild species 5 (3) 0 21 (11) Unknown source animal 0 5 (9) 20 (11) Mean age (y) 22.5 16.2 26.6 * Route of exposure and source of exposure percentages calculated within group size to accommodate comparison. ([dagger]) Bite exposure was significantly associated with single-person exposures vs. group exposures (p<0.001). Table 4. Human rabies postexposure prophylaxis (PEP), 4 counties, New York, 1993-2000 Characteristic 1993-1994 * PEP cases (annual mean) 1,173 (587) Annual PEP incidence 32/100,000 urban, 123/100,000 rural Season Summer to early autumn Sex 55% male (47/100,000), 45% female (38/100,000) Age (y) ([dagger]) 10-14 and 35-55 Exposure source (%) Wild 67 Raccoon 50 Bat 5 Other 12 Domestic 33 Cat 17 Dog 14 Other 2 Exposure type (%) Bite 30 Scratch 6 Direct ([double dagger]) 14 Indirect ([section]) 51 Group size 47% [greater than or equal to] 2 persons exposed Characteristic 1995-2000 PEP cases (annual mean) 2216 (369) Annual PEP incidence 23/100,000 urban, 57/100,000 rural Season Summer to early autumn, July-August for 1998-2000 Sex 51 % male (27/100,000), 49% female (25/100,000) Age (y) ([dagger]) 5-9 and 30-34 Exposure source (%) Wild 51 Raccoon 12 Bat 31 Other 8 Domestic 49 Cat 24 Dog 23 Other 2 Exposure type (%) Bite 51 Scratch 5 Direct ([double dagger]) 16 Indirect ([section]) 28 Group size 40% [greater than or equal to] 2 persons exposed * Data from Centers for Disease Control and Prevention (9). ([dagger]) Age groups with highest annual incidence. ([double dagger]) Direct exposure of saliva or neural tissue to wound or mucous membrane. ([section]) Indirect exposure to saliva or neural tissue to wound or mucous membrane, includes unidentified exposures from 1995 to 2000.