In July 2016, I wrote a blog post entitled Rabies Prevention and Control: Integrating Recent Research into North Carolina’s Legal Framework. It tells the story of Duke – a dog that was potentially exposed to rabies. Since that time, the North Carolina General Assembly enacted legislation that will have a significant impact on public health practice as it relates to rabies post-exposure management for dogs, cats, and ferrets. Rather than retract my old blog post, I thought I would tell Duke’s story again but change the outcome to reflect the changes in the law.

I’ll talk a little bit about animal services in our upcoming Local Government Legislative Update Webinar. Several of my colleagues will be joining me to discuss changes and pending legislation in areas such as public records, land use and planning, elections administration, and public health. If you aren’t able to join us for the live program on Tuesday, July 25, the on-demand version will be available on our website shortly thereafter.

Enough marketing.  Read on to hear what happens to dear old Duke…

Your dog, Duke, is outside in the yard and has an unexpected encounter with a raccoon. The raccoon bit Duke and there is a small break in the skin on his leg. At this point, public health’s rabies prevention and control system is set in motion. This post briefly walks through the legal framework for responding to suspected rabies exposures, including requirements related to booster shots, euthanasia, and quarantine.

Required vaccination

The cornerstone of the rabies law is the requirement that dogs, cats, and ferrets (four months and older) have current rabies vaccinations. G.S. 130A-185. Dogs must wear rabies tags at all times and may be impounded if they are found at-large without one. G.S. 130A-192. State law also requires cats and ferrets to wear tags, but a local government may adopt an ordinance exempting them from this requirement. If an animal owner fails to comply with these requirements, the owner may be charged with a Class 1 misdemeanor or the local health director may seek an injunction. G.S. 130A-18; G.S. 130A-25. In our story, let’s assume that Duke is 8 years old. He was first vaccinated when he was 12 weeks old and then received a booster one year later, consistent with the recommended schedule for puppies. Since then, the schedule slipped a little bit. He received a three-year vaccine when he was about 4.5 years old but hasn’t received any since that time. Therefore, he is about 6 months late on his vaccination.

Exposed?

After Duke’s run-in with the raccoon, you should notify the local health director or animal services department about the potential exposure. (Note: the rest of this post will refer to the health director as the decision-maker because that is how the law is written but some health directors have delegated these duties to animal services officials in other departments, which is authorized by G.S. 130A-6.)

The health director will evaluate the facts of the situation and determine whether Duke has been “exposed to the saliva or nervous tissue of a proven rabid animal or animal reasonably suspected of having rabies that is not available for laboratory diagnosis.” G.S. 130A-197. Let’s consider two alternative versions of our story:

• Version 1: Assume Duke attacked the raccoon and killed it. Because the raccoon’s body is available, the health director will likely send its head to the laboratory for rabies testing. If the test comes back negative, Duke will not be considered to have been exposed to rabies. If it comes back positive, unsatisfactory, indeterminate, or “test not performed” Duke will likely be considered exposed.
• Version 2: Assume the raccoon ran away after biting Duke. Because the prevalence of rabies in raccoons is high, the health director will almost certainly conclude that Duke was exposed.

Sometimes these situations are not so clear cut. The health director will need to evaluate all of the facts of the particular situation and decide whether he or she “reasonably suspects” that there has been an exposure. In making this determination, the director will rely on guidance from the state Division of Public Health Communicable Disease Branch and the U.S. Centers for Disease Control, and may consult with the state’s public health veterinary team. Let’s assume for the purpose of our story that the health director concluded that Duke was exposed to rabies.

Exposed!

Once you learn that Duke was exposed to rabies, the public health or animal services officials will outline your options for managing his exposure.

Until recently, the research strongly suggested euthanizing or requiring a six-month quarantine for exposed animals that were never vaccinated as well as those that were overdue for their vaccinations. The law authorized the director to order a quarantine for a period “up to” six months.  Therefore, many health directors required 6 month quarantines for all exposed cats, dogs, and ferrets. The law required that quarantines take place at “a facility” approved by the health director which resulted in many health directors requiring that the animal be housed at a public animal shelter or a veterinary hospital. Because the cost of impounding an animal for this extended period of time can be high, some owners elected to euthanize the animal instead of quarantining it. Some health directors allowed some or all of the quarantine period to be completed in the home, subject to certain restrictions and continuing oversight.

In March 2016, the National Association of Public Health Veterinarians (NASPHV) published revised guidance that addresses how veterinarians and public health officials should manage rabies exposures for dogs, cats, and ferrets.  The NASPHV guidance recommends a complex approach that differentiates between animals that have never been vaccinated and those that are overdue. This change in course is based on research indicating that an animal that is overdue for a vaccination is likely to mount a robust immune response if a booster is provided.

The new NASPHV recommendations are as follows:

• Dogs, cats, and ferrets that have never been vaccinated should be euthanized immediately or placed in strict quarantine for 4 months (dogs and cats) or 6 months (ferrets). The quarantine should be in an enclosure that precludes direct contact with people or other animals. If quarantined, the animal should be vaccinated within 96 hours of exposure. If the vaccination is delayed, public health officials should consider extending the quarantine period.
• A dog or cat that has appropriate documentation (NASHPV Form #51 or a rabies certificate with the same information) showing it is either current on its vaccinations or was vaccinated at least once previously should receive a booster vaccination within 96 hours of exposure. In addition, the owner should keep the animal under his or her control and observe it for 45 days for signs of illness. If the booster is delayed, public health officials should consider increasing the observation period. Note that the guidance does not recommend quarantine for these animals.
• If an owner states that the dog or cat has had a rabies vaccination in the past but does not have the appropriate documentation to prove it, the guidance offers two options: (1) follow the quarantine approach for described above for animals that have never been vaccinated or (2) consider allowing blood testing to evaluate whether there is evidence a robust immune response upon booster vaccination.
• A ferret that has a lapsed vaccination should be “evaluated on a case-by-case basis” to determine the appropriate management.

After this revised guidance was issued in 2016, some North Carolina health directors were trying to decide whether they should follow the new guidance or stick with the more rigid quarantine/euthanasia options in state law. Some local boards of health adopted rules specifically authorizing the health director to follow the new guidance. My earlier blog post discussed some of the issues related to adopting such rules. The state’s Division of Public Health also updated the NC Rabies Control Manual, the Veterinary Public Health Bulletin Board, and developed some helpful algorithms to help guide those health directors who were following the more flexible NASPHV guidance. Based purely on anecdotal feedback from health directors, I suspect we had significant variation across the state this past year as it relates to post-exposure management.

New Legislation

In 2017, the General Assembly revised the statute (G.S. 130A-197) that governs post-exposure management. S.L. 2017-106 removes all of the language that previously required euthanasia or quarantine. In its place, the law now refers directly to the NASPHV guidance. Beginning October 1, 2017, health directors will be required to look to the guidance for direction on how to manage exposures of cats, dogs, and ferrets.

I anticipate this legislation will result in several changes in law and practice:

• Fewer quarantines: According to the guidance, any dog, cat, or ferret that (1) has a lapsed vaccination and (2) receives a booster within 96 hours of exposure will be allowed to go home. The animal must be observed by the owner for 45 days for signs of illness and remain under the owner’s control for that same period of time. Note that the guidance requires “observation” rather than “quarantine” or “confinement.” Under the previous law, these animals would have been either euthanized or quarantined for up to six months at the owner’s expense. This is a major change in the animal services world.
• Repealed board of health rules: All counties should review their board of health rules and ordinances to ensure they are not in conflict with the revised state law. Local boards of health that adopted rules authorizing the health director to follow the NASPHV guidance will be able to repeal those rules.  Because only some counties adopted such rules in the last year, this change will not impact every county. It will, however, ensure that the law governing rabies post-exposure management is consistent across the state.
• New interest in blood testing: If the owner of an animal that has been exposed is not able to provide documentation of a past rabies vaccine, the NASPHV guidance allows blood testing for the animal as a method for evaluating its immune response as evidence of prior rabies vaccination. Details for this testing (called Prospective Serologic Monitoring) are available here and here. This relatively new approach will require some training and adjustment from city and county animal services and public health staff as well as the veterinary community. It is important to note that the health director has the authority to refuse to allow blood testing.

So what is going to happen to Duke?  If the exposure happens on August 1, it is possible that the health director may require quarantine for up to six months at a shelter or veterinarian’s office, unless Duke is in a county that has adopted local board of health rules.  If it happens on October 5, Duke will likely be getting a booster shot, a dog treat, and a ride home for a 45-day owner observation period.

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