Rabies Investigations: Are we chasing our
tail?
2008 - 2009
Environmental Public Health Leadership Institute Fellow:
Robyn M. Atkinson, PhD, HCLD
Director, Knoxville Regional Laboratory; Tennessee Department of Health Division of
Laboratory Services
1522 Cherokee Trail
Knoxville TN 37920
(865) 549-5217
robyn.atkinson@state.tn.us
Mentor:
Trevor D. Coke
Environmental Supervisor II; Miami Dade County Health Department Environmental
Health and Engineering Division
Acknowledgements:
Palik Raval-Nelson, PhD, MPH
Chief, Office of Food Protection; City of Philadelphia Department of Public Health
2008–2009 Fellow Project
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EXECUTIVE SUMMARY:
The endemic transmission of canine variant rabies virus was eliminated in the United States
during an aggressive domestic animal vaccination campaign during the 1940-50’s (1). Today,
the main reservoir of rabies virus in the United States is wild animals such as raccoons and bats.
Of the 37 human deaths in the US linked to rabies virus from 1995-2006, 28 were bat exposures,
1 was a raccoon bite, and 8 were dog encounters, yet all dog encounters occurred outside of the
US (2). Data demonstrates the largest threat to humans for contracting rabies in the US is
interactions with the bat population. However, the rabid raccoon population is extending
westward over the Appalachian Mountains into the Northeast and Southeast portions of
Tennessee. As a result, the number of rabid raccoons has increased steadily in TN over the last 5
years. This introduction of rabies into TN via a vector that is very social increases the likelihood
that domestic animals in the area may be at an increased risk of acquiring rabies and thereby
transmitting the disease to their human owners. National guidelines and state laws regarding a
rabies exposure investigation are vague in certain aspects and do not specifically dictate which
agency should head up the investigation (3,4). This is an opportunity for interpretation and may
lead to disorganization and miscommunication. One example of this miscommunication is
represented by the fact the TN Department of Health Laboratory Services receives roughly 1,300
domestic animal heads a year for rabies testing compared to roughly 600 wild animal heads.
This ratio of domestic to wild animals seems disproportionate to the current reality of rabies in
TN.
In an effort to understand this discrepancy, a systems thinking approach (5) was applied to the
process of rabies exposure investigations to understand why so many domestic animals are
determined to be at risk for rabies transmission to humans. This project reviewed the process of
rabies investigations and identified 8 public health agencies and community partners that may be
involved in a single case investigation. Among the 3 public health agencies, a shifting-theburden mental model limits the creation of an orderly and fact-based analysis of the exposure.
Fear among the community regarding rabies disease often drives euthanasia and testing of
animals without properly assessing the situation. Via the creation of a rabies investigation
oversight and review committee, all stakeholders are working toward agreement on a policy to
assure all investigations follow a standardized procedure. This procedure aims to highlight true
cases of rabies exposures, to ensure proper treatment of the exposed individuals, and to limit the
number of animal heads submitted for rabies testing. The plan implements many of the Public
Health Environmental Standards; it educates and informs the public, it develops polices, it
enforces laws, and it mobilizes community partnerships. Ultimately, this plan will be shared
with national advisory boards as a new method for rabies investigations.
INTRODUCTION/BACKGROUND:
The movie “Old Yeller” is near and dear to the hearts of many individuals as it is the touching
story of a young boy and his dog. The ending of the movie can make even the toughest person
teary eyed as the young boy learns the reality of the situation when Old Yeller contracts rabies
and must be killed. This is still the paradigm that many associate with rabies disease and many
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still fear domestic animal aggression is the result of rabies virus infection. However, canine
variant rabies virus was eradicated in the United States in the 1940-50’s as a result of an
aggressive vaccination campaign. Currently, the largest threat of rabies virus nationwide is via
interactions with the bat population. Bat variant rabies is considered endemic to the United
States and of the 37 human deaths in the US linked to rabies virus from 1995-2006, 28 were due
to exposures to bats. Skunk variant rabies virus and raccoon variant rabies virus are endemic to
certain areas of the United States. The zone for raccoon variant rabies extends along the eastern
seaboard from Florida north to Maine. It was widely believed that the Appalachian Mountains
would prevent the spread of raccoon rabies westward into the mid-southern and mid-western
areas of the country. However, the zone is slowly extending westward over and around the
mountains into the Northeast and Southeast areas of Tennessee as well as Kentucky, Virginia,
and Northern Georgia. This encroachment of rabid raccoons into a naive population provides a
breeding ground for the raccoon variant rabies viruses to spread and infect new hosts. The prime
hosts are domestic pet animals not up-to-date on their rabies vaccinations. Often rabid raccoons
will become aggressive and will enter dog pens, climb over back-yard fences, and often chase
domestic animals.
Since the late 1950’s, vaccination of the domestic animal population has been highly encouraged
by veterinarians and public health officials to keep the United States free of the disease. While
this vaccine is highly effective for preventing canine variant rabies in dogs and cats, it is believed
to provide cross-protection against raccoon variant rabies. Therefore, vaccination is especially
important for all pets, especially in zone-bordering areas such as TN.
The emergence of raccoon rabies in East TN has created a need to reassess how possible rabies
exposures are handled by public health officials focusing on interactions between domestic and
wild animals. The paradigm of fear still exists in the community and even in some animal
control agencies. They believe that any domestic animal that bites a human must have rabies and
that animal should be euthanized and tested. This attitude leads agencies charged with animal
bite investigations to make the broad leap that any domestic animal that bites needs testing.
Such action is against national guidelines and state law. National guidance from CDC and
AVMA state that a healthy domestic animal which has bitten a human should be observed for 10
days. Once the animal becomes ill during observation, the animal must be euthanized and tested
for rabies virus infection. If all agencies involved were following this procedure, it is expected
that the numbers of domestic animals sent for testing would remain small. However, for
example, one TN county reported 137 dog bites within the county in 2007 (personal
communication). Laboratory records indicate that 136 dog heads were submitted for testing
from the animal control agency involved in those bite investigations. Overall, the TN
Department of Health Laboratory System receives roughly 1,300 domestic animal heads a year
for rabies testing compared to roughly 600 wild animal heads. This ratio of domestic to wild
animals seems disproportionate to the current reality of rabies in TN.
Inquiries into the case investigation of a single domestic animal head submitted to the laboratory
for testing revealed at least 8 different state and local agencies and community partners may be
involved in a single investigation. Three of the 8 agencies involved in the investigation of a
single exposure are under the umbrella of public health. Often times these agencies do not
communicate in a timely manner and in the event of a positive rabies test, reporting of results
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and administration of prophylaxis can be significantly delayed to the detriment of the human
exposed. The establishment of a formal, orderly, and timely investigation procedure would
allow for the assessment of all animal bites to determine medical needs, identify all legitimate
rabies exposures, and thereby determine which animals to send to the laboratory for testing. The
hope is to eliminate unnecessary testing and euthanasia of domestic animals and ensure
education of the public regarding rabies epidemiology and transmission.
Problem Statement:
The lack of education among community partners and the lack of an orderly rabies exposure
investigation may mistakenly subject domestic animals to euthanasia and testing for rabies virus
infection in TN.
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Behavior Over Time Graph:
# of Domestic Animals
received for testing
Epidemiology Involvement
Incidence of Raccoon
and Skunk Rabies
# of Domestic
Biting Animals
Reported
Canine Rabies
Time
Knowledge regarding the current status of rabies virus distribution and its various infectious hosts has not worked to change
the current paradigm regarding dogs and rabies. This graph over time represents a disconnection between the number of
domestic animal heads received for testing and the current status of canine rabies in the United States.
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Causal Loop Diagrams and applicable Archetypes:
Shifting-The-Burden
The lab is expected to
test all specimens
submitted without
asking questions
The lab is
losing money
because of unrestricted and
un-necessary
testing
“I am not going to
be the one who
gets sued
because the
animal was not
tested and
someone died.”
Epidemiology’s job is
to protect the public
so we only become
involved in cases that
are positive.
Epidemiology to
screen all
submissions
B
# of Domestic animals
submitted for testing
B
Limit testing to
animals that have
demonstrated a true
risk for rabies
transmission
R
Organized checklist to
perform a risk-based
assessment to identify
animals with true risk
of transmitting rabies
Epidemiology overworked and cannot
keep up with
demand
Epidemiology time and
resources are
compromised limiting
their ability to achieve
the fundamental
solution
This diagram shows how the initial efforts of the epidemiologists and the environmentalists to lessen their workload shift the
burden to the lab; highlighting the need for an organized assessment of the exposure so that all agencies share the burden.
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10 Essential Environmental Health Services:
This project seeks to provide six of the 10 essential Environmental Health Services.
Inform, Educate, and Empower the public about environmental health issues. A significant
potion of this project is dedicated to streamlining and synchronizing the education of all agencies
charged with the investigation of potential rabies exposures: environmentalists, animal control,
and epidemiologists. The project also identifies the need to inform and educate veterinarians,
animal shelters, and the public regarding the state of rabies in Tennessee.
Mobilize Community Partnerships. The project describes the need to reach out to the public and
local agencies such as veterinarians, animal shelters, and responsible pet owners. This can be
accomplished through pet vaccination clinics, community seminars, continuing education
seminars, and open houses encouraging the public to meet public health staff. Through
education the community may be empowered to work together to see that all domestic animals
are protected.
Figure 1: Osaki, Ten Essential Environmental Public Health Services
Develop Policies and Plans. This project’s main focus is to put into practice a comprehensive
and orderly policy and procedure for the investigation of potential rabies exposures. This plan
will seek to ensure that all agencies are aware of the incident and are prepared to act accordingly
following the guide set forth for their involvement. The intent is to guarantee treatment to the
affect human as soon as possible.
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Enforce Laws and Regulations. In an effort to reduce the number of domestic animals sacrificed
and tested for rabies infection, the new policy will seek to first enforce laws and regulations
regarding pet vaccination, 10-day observations, consulting public health, and fines for dangerous
dog/irresponsible pet ownership. The state will no longer accept the burden for irresponsible pet
ownership. Animal control agencies and the courts must work to enforce leash laws, fines for
dog’s being off owner property, etc.
Link people to needed services. This will be achieved in combination with mobilizing the
community through pet fairs, pet vaccination clinics, local veterinary seminars, and open houses
at health departments and animal shelters.
Assure a competent workforce. This service will be met in combination with efforts to inform
and educate the public health agencies and their community partners regarding rabies and its
impact in TN.
National Goals Supported
This project aims to support four of the Center for Disease Control and Prevention’s “Healthy
People 2010” objectives. Rabies control and prevention is a unique program. Programs aim to
take care of domestic animals with the valued by-product of protecting the human population
from the disease. This project aims to 1) provide humans better access to health care services in
the event they are exposed to the rabies virus, 2) educate and build community based programs
targeting prevention of rabies in domestic animals, 3) support and re-build the public health
infrastructure that supports rabies case investigations, and 4) provide valuable immunizations to
pets and humans in an effort to keep canine rabies virus out of the United States.
This project supports three of the goals of the National Strategy to Revitalize Environmental
Public Health Services:
Goal IV – Communicate and Market
A major goal of this project is to communicate the role of state and local agencies
involved in rabies investigations to the community. Through this communication, the
project highlights the assets available to the public via public health agencies.
Goal V – Develop the workforce
The commitment to improving rabies investigations can only be achieved through a
competent and educated workforce. This project outlines much needed education of the
workforce.
Goal VI – Create Strategic Partnerships
Public health cannot function alone. In order to ensure that all humans are protected from
a potentially rabid animal, public health must strive to work with law enforcement,
animal shelters, and veterinarians in their area to achieve success.
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The education of public health agencies, most notably the environmental health specialists
charged with rabies investigations, fulfills the goals of the Environmental Health Competency
Project: Recommendation for Core Competencies for Local Environmental Health Practitioners.
This project supports the education and communication core competencies.
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Project Logic Model: Problem Statement - The lack of education among community partners and the lack of an orderly rabies exposure investigation
unnecessarily subject domestic animals to euthanasia and testing for rabies virus infection in TN.
Resources/Inputs
Funding
 County
 State
 Vet College
 City
City and County
Partners
Animal Control
Environmentalists
Health Officer
Time and
Knowledge
Academic
Partners
UT Vet School
Clinical
Social Work
Veterinarians
State Partners
 GEH
 HSA
 Laboratory
Services
Activities
Rabies Task Force
 Engage stakeholders
 Conduct needs assessment
 Develop objectives
 Develop communication
strategy
 Select instructors for training
and seminars
 Develop curriculum and agenda
for training and seminars
 Design brochure and handout
content and layout
In-service and Seminars
 Conduct pre-training
assessments
 Conduct in-service for
stakeholders
 Conduct seminars for
veterinarians
Rabies Vaccination Clinics
 Distribute Brochure and
handout
 One-on-one sessions with
veterinarian and concerned
citizens
Outputs












# of meetings
Training curriculum
Training sessions
Investigation checklist
Brochure/handout for public
# individual assessments
# persons trained
diversity of persons trained
#, scope, and focus of trainings
Checklist implemented
Collaboration established
All stakeholders with the same
knowledge base
 Educated public
 More animals receive
vaccinations
 Less fear and panic associated
with an animal bite
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Short & Long Term Outcomes, Impacts.
Learning
 Understanding of each
stakeholder’s role in an
investigation
 Understanding of each
stakeholder’s motivation
 Establishment of a
coordinated investigation
Learning
 Increased knowledge and
awareness of rabies
epidemiology and biology
 Establishment of their role
in an investigation
 Greater appreciation of a
partnership
 Great ability to deal with the
public and counsel families
involved in an investigation
Learning
 Understanding of rabies
biology
 Greater assurance with the
investigation process
 Less fear
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Behavior
 Act not react
 Assess each case
individually
 Limit number of
domestic
animals
submitted for
testing
Results
 Reduced number
of animals
processed by the
laboratory
 Monetary
savings
 Safer laboratory
environment
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PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:
Program Goal
1) To create a consistent Rabies/animal bite investigation protocol allowing for better risk
assessment and communication among all stakeholders.
2) To reduce the number of domestic animals submitted for laboratory testing to only those
animals with a true risk of infection.
Health Problem
Excessive numbers of domestic animals are euthanized and sent for rabies virus testing without
proper screening for risk factors and/or rabies risk to human handlers or owners.
Outcome Objective
By June 30, 2009, reduce the number of domestic animal heads submitted for testing by 50% of
the previous year (July 1, 2007 to June 30, 2008).
Determinant
The number of domestic animal heads submitted for rabies testing at the Knoxville Regional
Laboratory.
Impact Objective
By February 28, 2009, all stakeholders involved in rabies/animal bite investigations will utilize a
common investigation protocol to determine appropriateness of euthanasia and testing.
Contributing Factors
1. Lack of understanding each partner’s position in the investigation. All parties operate
under their own set of rules without regard for how their actions affect other partners.
2. Lack of knowledge or lack of training on how to address public fears and concerns
regarding rabies and animal bites. Partners often become flustered and excitable which in
turn may escalate an already tense situation. This often leads to stakeholders giving into
public fears and pressure.
3. Fear among stakeholders. Fear of lawsuits in the event a situation is not handled
correctly and fear of not catching a potential rabies exposure leading to an individual’s
death. This often leads to overcompensation and a “no-thinking attitude” of “test all
biting animals for rabies.”
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4. Resource and cost limitations for implementation of 10-day observation periods for
domestic animals that bite a person. Animal control policies not permitting at-home
observation.
Process Objectives
1. By February 28, 2009, a common case investigation protocol will be ready for
implementation.
2. By April 30, 2009, all stakeholders will be educated as to the current epidemiology of
rabies in Tennessee, the current literature regarding the biology of rabies virus
transmission, and the use of the new case investigation protocol.
3. By June 30, 2009, stakeholders will create a handout or brochure for the community that
outlines the social, legal, and medical aspects of a possible rabies exposure and provides
information on where to seek assistance in the event of an animal bite or exposure.
METHODOLOGY:
Events and Activities
1. In an effort to create a standardized rabies case investigation procedure, a panel of
representatives from each of the 8 agencies involved in the investigation process was
created. This group meets once a month: to assess each stakeholder’s duties, to discuss
the types of information that needs to be collected and shared with all stakeholders, to
establish a communication tree to ensure that all stakeholders are involved, and to
establish a checklist to be used in all investigations which guides the process allowing for
consistency and timely notification.
2. Once all stakeholders have agreed on an investigation process, in-service/training
seminars will be created for environmentalists, animal control officers, animal shelter
personnel, and continuing education seminars for veterinarians. Stakeholder
representatives must decide on the content of the curriculum of in-service training and
seminars, identify instructors for training and seminars, plan training and seminar
sessions agenda, and identify facilities and dates to hold training and seminars.
3. In an effort to involve, empower, and educate the community, yearly rabies vaccination
clinics will be established. Stakeholder representatives must decide on the content and
layout of the brochure, have the brochure drafted and reviewed by a larger meeting of
stakeholders, and ensure the brochure is printed in mass quantity. This brochure is to be
handed out at yearly rabies vaccination clinics throughout the state as well as to all
families involved in an animal bite/rabies exposure investigation.
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RESULTS:
As usual, when dealing with multiple agencies and partners, results do not happen as fast as
initially intended. All stakeholders have agreed: 1) implementation of the 10-day observation
period will be enforced when ever possible (criteria needed to allow for home observation still
need to be assessed and brought into conjunction with national guidance); 2) at the time the
animal under observation becomes ill or if the animal is ill when the bite or mucous membrane
exposure occurs, an environmentalist, an epi-nurse, an epidemiologist, or a health officer will be
contacted regarding the case. Once an investigation determines the animal is a high risk for
rabies transmission, the health officer will order the animal be tested for rabies. Animals
received into the laboratory with a written order from public health will be tested for no charge.
Animals submitted without following this procedure will be processed for a $160 fee.
NEXT STEPS:
Upcoming meetings of the stakeholders will address criteria for home observation, creation of
educational materials and seminars for all employees within the stakeholders’ agencies, and
begin drafting a brochure for the public to be handed out at the spring and early summer rabies
vaccination clinics.
LEADERSHIP DEVELOPMENT OPPORTUNITIES:
Robyn M Atkinson
This year being a fellow in the National Environmental Public Health Leadership Institute has
been very rewarding offering many opportunities for personal growth and reflection. When I
began this fellowship, I was new to my position in TN and was facing for the first time the
complicated world of management and administration. I was hesitant to take on this task at first
but the knowledge and perspective I have gained have been immeasurable. Last year, I was
quick to make decisions, often short sighted thereby missing the bigger picture or meaning of the
situation, and taking on responsibilities that I should have delegated to others. By working with
a personal coach, I was able to see how these traits were hurting not helping and I was able to
define strategies to help manage my staff rather than micro-manage them. The orientation to
Systems Thinking and how to speak to people and fully understand what they are saying has
helped me from the moment I returned from the learning sessions. As a manager, I am much
more comfortable delegating responsibility. I have received positive feedback from staff
members regarding my ability to listen and respond to the situation at hand and not get caught up
in “off the track” ideas. In meetings, I am able to see all sides of a problem and offer a
compromise that may help all involved. Overall, I am a more aware project manager, a much
calmer staff manager, and a better representative of the public health community. This
experience has been invaluable and I strive to remember all of the lessons learned as we are
ushered out and others are ushered in to this amazing leadership experience.
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ABOUT THE EPHLI FELLOW
Robyn M Atkinson, PhD is currently the Director of the Knoxville Regional Laboratory
for the Tennessee Department of Health Division of Laboratory Services. She also serves
as the Deputy Director for the state laboratory system. Dr Atkinson holds a Bachelor’s
Degree in Biochemisty from Clemson University in South Carolina. She continued her
education by completing a Doctorate of Philosophy Degree in Microbial Pathogenesis at
the University of Tennessee – Health Sciences Center. Her research focus was
antimicrobial resistance in Streptococcus pneumoniae, one of the leading causes of ear
infections in children. Her research laboratory was based at St Jude Children’s Research
Hospital and during her years there, she was exposed to the career of clinical
microbiologist which joins classical research with clinical practice. Therefore upon
graduation, she completed a fellowship in Medical and Public Health Microbiology at
Washington University in St Louis School of Medicine. During this fellowship, Dr
Atkinson was introduced to public health and public health microbiology. She
discovered a keen interest in learning about disease processes in the community vs.
focusing on the disease process in the individual. She was excited to join the New York
State Department of Health as the Director of Clinical Bacteriology. While in this
position, Dr Atkinson was exposed to the numerous and complex issues regarding food
safety as well as standardization of laboratory practices among all state and local public
health laboratories. After spending 2 years in New York, she was recruited to her current
position in TN. While in TN, she has continued her focus on food safety by becoming a
member of the Tennessee Food Safety Task Force and a member of the Association of
Public Health Laboratories (APHL) Food Safety Committee. She was recently named a
Member-at-Large to an FDA Coordinating Committee on Food Safety. Through APHL,
she has also been given the opportunity to begin to streamline standards of practice across
all state and local public health laboratories by working with subject matter experts to
draft Best Practices Guidelines for the isolation and characterization of several infectious
organisms of public health significance.
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REFERENCES
1. Smith, J.S. New Aspects of Rabies with Emphasis on Epidemiology, Diagnosis, and
Prevention of the Disease in the Untied States. Clin Micro Rev, 1996 9:2:166-176.
2. Blanton, J.D., Hanlon, C.A., and Rupprecht, C.E. Rabies Surveillance in the United
States During 2006. JAVMA, 2007: 231: 4.
3. CDC. Human Rabies Prevention – United States, 2008. MMWR 2008;57:RR-3.
4. CDC. Compendium of Animal Rabies Prevention and Control, 2008. MMWR 2008;
57:RR-2.
5. Senge, P. M., Kleiner, A., Roberts, C., Ross, R. B., & Smith, B. J. The Fifth
Discipline Fieldbook, Strategies and Tools for Building a Learning Organization. 2004.
New York: Doubleday.
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