A recombinant vaccinia-rabies virus in the immunocompromised host: oral innocuity, progressive parenteral infection, and therapeutics

Oral vaccination of wildlife using a vaccinia-rabies-glycoprotein recombinant virus vaccine (RABORAL V-RG®): a global review

RABORAL V-RG® is an oral rabies vaccine bait that contains an attenuated ("modified-live") recombinant vaccinia virus vector vaccine expressing the rabies virus glycoprotein gene (V-RG). Approximately 250 million doses have been distributed globally since 1987 without any reports of adverse reactions in wildlife or domestic animals since the first licensed recombinant oral rabies vaccine (ORV) was released into the environment to immunize wildlife populations against rabies. V-RG is genetically stable, is not detected in the oral cavity beyond 48 h after ingestion, is not shed by vaccinates into the environment, and has been tested for thermostability under a range of laboratory and field conditions. Safety of V-RG has been evaluated in over 50 vertebrate species, including non-human primates, with no adverse effects observed regardless of route or dose. Immunogenicity and efficacy have been demonstrated under laboratory and field conditions in multiple target species (including fox, raccoon, coyote, skunk, raccoon dog, and jackal). The liquid vaccine is packaged inside edible baits (i.e., RABORAL V-RG, the vaccine-bait product) which are distributed into wildlife habitats for consumption by target species. Field application of RABORAL V-RG has contributed to the elimination of wildlife rabies from three European countries (Belgium, France and Luxembourg) and of the dog/coyote rabies virus variant from the United States of America (USA). An oral rabies vaccination program in west-central Texas has essentially eliminated the gray fox rabies virus variant from Texas with the last case reported in a cow during 2009. A long-term ORV barrier program in the USA using RABORAL V-RG is preventing substantial geographic expansion of the raccoon rabies virus variant. RABORAL V-RG has also been used to control wildlife rabies in Israel for more than a decade. This paper: (1) reviews the development and historical use of RABORAL V-RG; (2) highlights wildlife rabies control programs using the vaccine in multiple species and countries; and (3) discusses current and future challenges faced by programs seeking to control or eliminate wildlife rabies.

Enhanced efficacy of cidofovir combined with vaccinia immune globulin in treating progressive cutaneous vaccinia virus infections in immunosuppressed hairless mice

The treatment of progressive vaccinia in individuals has involved antiviral drugs, such as cidofovir (CDV), brincidofovir, and/or tecovirimat, combined with vaccinia immune globulin (VIG). VIG is costly, and its supply is limited, so sparing the use of VIG during treatment is an important objective. VIG sparing was modeled in immunosuppressed mice by maximizing the treatment benefits of CDV combined with VIG to determine the effective treatments that delayed the time to death, reduced cutaneous lesion severity, and/or decreased tissue viral titers. SKH-1 hairless mice immunosuppressed with cyclophosphamide and hairless SCID mice (SHO strain) were infected cutaneously with vaccinia virus. Monotherapy, dual combinations (CDV plus VIG), or triple therapy (topical CDV, parenteral CDV, and VIG) were initiated 2 days postinfection and were given every 3 to 4 days through day 11. The efficacy assessment included survival rate, cutaneous lesion severity, and viral titers. Delays in the time to death and the reduction in lesion severity occurred in the following order of efficacy: triple therapy had greater efficacy than double combinations (CDV plus VIG or topical plus parenteral CDV), which had greater efficacy than VIG alone. Parenteral administration of CDV or VIG was necessary to suppress virus titers in internal organs (liver, lung, and spleen). The skin viral titers were significantly reduced by triple therapy only. The greatest efficacy was achieved by triple therapy. In humans, this regimen should translate to a faster cure rate, thus sparing the amount of VIG used for treatment.

National surveillance for human and pet contact with oral rabies vaccine baits, 2001-2009

OBJECTIVE

To determine the rate and absolute number of human and pet exposures to oral rabies vaccine (ORV) bait containing liquid vaccinia rabies glycoprotein recombinant vaccine and to evaluate factors that might affect human contact with bait to modify the program and reduce human exposure to the vaccine.

DESIGN

Retrospective analysis of surveillance data (2001 to 2009).

SAMPLE

Reports on human and pet contact with ORV baits in states with ORV surveillance programs.

PROCEDURES

Data were collected from passive, multistate ORV surveillance systems in Alabama, Arizona, Florida, Georgia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Tennessee, Texas, Vermont, Virginia, and West Virginia. Data collected included the nature of human or pet contact with bait and vaccine, the caller's knowledge of the ORV bait program, local human population density, and other relevant demographic data.

RESULTS

All 18 states participated in the surveillance program for at least 1 year, for a combined 68 years of observation. One thousand four hundred thirty-six calls were reported, representing 3,076 found baits (6.89/100,000 baits dropped); 296 (20%) calls were related to human contact with ruptured bait, and 550 (38%) involved pet contact with the bait. Six adverse events in humans were reported, one of which required hospitalization. Fifty-nine adverse events in pets were noted, all of which were nonserious.

CONCLUSIONS AND CLINICAL RELEVANCE

Findings from surveillance activities have been used to improve baiting strategies and minimize human and pet contact with ORV baits. Overall, human and pet contact with ORV baits was infrequent. Surveillance has led to early identification of persons exposed to ORV and rapid intervention.

Postexposure prevention of progressive vaccinia in SCID mice treated with vaccinia immune globulin

A recently reported case of progressive vaccinia (PV) in an immunocompromised patient has refocused attention on this condition. Uniformly fatal prior to the licensure of vaccinia immune globulin (VIG) in 1978, PV was still fatal in about half of VIG-treated patients overall, with a greater mortality rate in infants and children. Additional therapies would be needed in the setting of a smallpox bioterror event, since mass vaccination following any variola virus release would inevitably result in exposure of immunocompromised people through vaccination or contact with vaccinees. Well-characterized animal models of disease can support the licensure of new products when human studies are not ethical or feasible, as in the case of PV. We chose vaccinia virus-scarified SCID mice to model PV. As in immunocompromised humans, vaccinia virus-scarified SCID animals develop enlarging primary lesions with minimal or no inflammation, eventual distal virus spread, and lethal outcomes if left untreated. Postexposure treatment with VIG slowed disease progression, caused local lesion regression, and resulted in the healthy survival of most of the mice for more than 120 days. Combination treatment with VIG and topical cidofovir also resulted in long-term disease-free survival of most of the animals, even when initiated 7 days postinfection. These results support the possibility that combination treatments may be effective in humans and support using this SCID model of PV to test new antibody therapies and combination therapies and to provide further insights into the pathogenesis and treatment of PV.

Rabies surveillance in the United States during 2008

During 2008, 49 states and Puerto Rico reported 6,841 cases of rabies in animals and 2 cases in humans to the CDC, representing a 3.1% decrease from the 7,060 cases in animals and 1 case in a human reported in 2007. Approximately 93% of the cases were in wildlife, and 7% were in domestic animals. Relative contributions by the major animal groups were as follows: 2,389 (34.9%) raccoons, 1,806 (26.4%) bats, 1,589 (23.2%) skunks, 454 (6.6%) foxes, 294 (4.3%) cats, 75 (1.1%) dogs, and 59 (0.9%) cattle. Compared with numbers of cases reported in 2007, numbers of cases reported in 2008 increased among cats, cattle, and skunks and decreased among dogs, raccoons, bats, and foxes. Numbers of rabid raccoons reported during 2008 decreased in 11 of the 20 eastern states where raccoon rabies was enzootic; overall number of rabid raccoons reported decreased by 8.6% during 2008, compared with 2007. On a national level, the number of rabies cases involving skunks increased by 7.7% during 2008, compared with the number reported in 2007; this was the first increase in the number of reported rabid skunks since 2006. The total number of cases of rabies reported nationally in foxes decreased 1.7% in 2008, compared with 2007. The 1,806 cases of rabies reported in bats represented a 6.7% decrease, compared with the number reported in 2007. One case of rabies in a dog imported from Iraq was reported at a quarantine station in New Jersey during 2008. Follow-up of potentially exposed animals in the same shipment did not reveal any secondary transmission. The United States remained free from dog-to-dog transmission of canine rabies virus variants. Total number of rabid dogs reported decreased 19.4% in 2008, compared with 2007. Two human rabies cases were reported from California and Missouri during 2008. The California case involved a recent immigrant from Mexico and was attributed to a newly identified rabies virus variant most likely associated with Mexican free-tailed bats. The case in Missouri was attributed to a rabies virus variant associated with eastern pipistrelle and silver-haired bats.

Safety studies on an adenovirus recombinant vaccine for rabies (AdRG1.3-ONRAB) in target and non-target species

A replication-competent human adenovirus vector in which the rabies virus glycoprotein gene was inserted (AdRG1.3-ONRAB) was given by direct instillation into the oral cavity to representatives of three wildlife vector species of concern in Ontario (red fox, raccoon and striped skunk) and to a variety of non-target wildlife species, domestic and laboratory species. Despite use of a relatively high dose of vaccine, no untoward clinical signs were observed. Subsequent to vaccine exposure, detection of vaccine virus in lung, spleen, intestine, liver, kidney and brain of each animal was attempted using an ONRAB-specific assay combining PCR with Southern blotting (PCR-SB). Of the 1280 tissue samples obtained from vaccinates or contact animals, 18 (1.4%) were found to be PCR-SB positive. Virus isolation attempts were performed utilizing cell culture for all PCR-SB positive tissues and a selection of PCR-SB negative tissues. Histological examination performed on all PCR-SB positive tissues failed to identify lesions attributed to the vaccine. A quantitative real-time PCR was used to determine the excretion of the vaccine in feces and in the oral cavity with 0.8% of oral swabs and 6.8% of fecal specimens found to be positive. The low rates of recovery of vaccine virus from tissues, feces and the oral cavity suggest that the likelihood of ONRAB causing a negative impact on wildlife species is unlikely.

Rabies surveillance in the United States during 2006

During 2006, 49 states and Puerto Rico reported 6,940 cases of rabies in animals and 3 cases in humans to the CDC, representing an 8.2% increase from the 6,417 cases in animals and 1 case in a human reported in 2005. Approximately 92% of the cases were in wildlife, and 8% were in domestic animals. Relative contributions by the major animal groups were as follows: 2,615 raccoons (37.7%), 1,692 bats (24.4%), 1,494 skunks (21.5%), 427 foxes (6.2%), 318 cats (4.6%), 82 cattle (1.2%), and 79 dogs (1.1%). Compared with numbers of reported cases in 2005, cases in 2006 increased among all groups except cattle. Increases in numbers of rabid raccoons during 2006 were reported by 11 of the 20 eastern states where raccoon rabies was enzootic, and reported cases increased by 3.2% overall, compared with 2005. On a national level, the number of rabies cases in skunks during 2006 increased by 6.1% from the number reported in 2005. Once again, Texas reported the greatest number (n = 351) of rabid skunks and the greatest overall state total of animal rabies cases (889). No cases of rabies associated with the dog/coyote rabies virus variant were reported. The last identified case of this canine rabies virus variant was identified in March 2004, along the US/Mexico border. With 2006 marking the second year of no apparent transmission of the dog/coyote variant, these findings from surveillance data support the contention that the canine rabies virus variant is no longer in circulation in the United States. Total number of cases of rabies reported nationally in foxes increased 13.6%, compared with 2005. Increases in the number of reported rabid foxes were attributable to greater numbers of foxes reported with the Arctic fox rabies virus variant in Alaska, the Texas gray fox rabies virus variant in Texas, and the raccoon rabies virus variant in Virginia. The 1,692 cases of rabies reported in bats represented a 14.5% increase, compared with numbers reported in 2005, making bats the second most reported rabid animal behind raccoons. Cases of rabies in cats, dogs, horses and mules, and sheep and goats increased 18.2%, 3.9%, 12.8%, and 22.2%, respectively, whereas cases reported in cattle decreased 11.8%. In Puerto Rico, reported cases of rabies in mongooses increased 9.2%, and rabies in domestic animals, presumably attributable to spillover infection from mongooses, increased 20%. Three cases of human rabies were reported from Texas, Indiana, and California during 2006. The cases in Indiana and Texas were attributed to bat rabies virus variants, whereas the case in California was attributed to an exposure to a dog in the Philippines.

Rabies surveillance in the United States during 2005

During 2005, 49 states and Puerto Rico reported 6,417 cases of rabies in nonhuman animals and 1 case in a human being to the CDC, representing a 6.2% decrease from the 6,836 cases in nonhuman animals and 8 cases in human beings reported in 2004. Approximately 92% of the cases were in wildlife, and 8% were in domestic animals. Relative contributions by the major animal groups were as follows: 2,534 raccoons (39.5%), 1,478 skunks (23%), 1,408 bats (21.9%), 376 foxes (5.9%), 269 cats (4.2%), 93 cattle (1.5%), and 76 dogs (1.2%). Compared with numbers of reported cases in 2004, cases in 2005 decreased among all groups, except bats, horses, and other wild animals. Decreases in numbers of rabid raccoons during 2005 were reported by 10 of the 20 eastern states in which raccoon rabies was enzootic and decreased overall by 1.2%, compared with 2004. On a national level, the number of rabies cases in skunks during 2005 decreased 20.4% from the number reported in 2004. Once again, Texas reported the greatest number (n = 392) of rabid skunks and the greatest overall state total of rabies cases (741). Texas reported no cases of rabies associated with the dog/coyote rabies virus variant and only 8 cases associated with the Texas gray fox rabies virus variant (compared with 22 cases in 2004). The total number of cases of rabies reported nationally in foxes decreased 3.3%, compared with those reported in 2004. The 1,408 cases of rabies reported in bats represented a 3.5% increase over numbers reported in 2005. Cases of rabies in cats, dogs, cattle, and sheep and goats decreased 4.3%, 19.2%, 19.1%, and 10%, respectively, whereas cases reported in horses and mules increased 9.3%. In Puerto Rico, reported cases of rabies in mongooses increased 29.8%, and rabies in domestic animals decreased 37.5%. One case of human rabies was reported from Mississippi during 2005. This case was submitted by the state to the CDC's unexplained deaths project and diagnosed as rabies retrospectively.

Rabies surveillance in the United States during 2004

During 2004, 49 states and Puerto Rico reported 6,836 cases of rabies in nonhuman animals and 8 cases in human beings to the CDC, representing a 4.6% decrease from the 7,170 cases in nonhuman animals and 3 cases in human beings reported in 2003. Approximately 92% of the cases were in wildlife, and 8% were in domestic animals (compared with 91% and 9%, respectively, in 2003). Relative contributions by the major animal groups were as follows: 2,564 raccoons (37.5%), 1,856 skunks (27.1%), 1,361 bats (19.9%), 389 foxes (5.7%), 281 cats (4.1%), 115 cattle (1.7%), and 94 dogs (1.4%). Compared with the numbers of reported cases in 2003, cases in 2004 decreased among all groups, except bats, cattle, human beings, and "other domestics" (1 llama). Decreases in numbers of rabid raccoons during 2004 were reported by 12 of the 20 eastern states in which raccoon rabies was enzootic. In the East, Massachusetts reported the first cases of raccoon rabies detected beyond the Cape Cod oral rabies vaccine barrier. Along the western edge of the raccoon rabies epizootic (Ohio in the north and Tennessee in the south), cases of rabies were reported from unexpected new foci beyond oral rabies vaccine zones. On a national level, the number of rabies cases in skunks during 2004 decreased by 12.1% from the number reported in 2003. Once again, Texas reported the greatest number (n = 534) of rabid skunks and the greatest overall state total of rabies cases (913). Texas reported only 1 case of rabies in a dog that was infected with the dog/coyote rabies virus variant and only 22 cases associated with theTexas gray fox rabies virus variant (compared with 61 cases in 2003). The total number of cases of rabies reported nationally in foxes and raccoons declined 14.7% and 2.7%, respectively, during 2004. The 1,361 cases of rabies reported in bats during 2004 represented a 12.3% increase over the previous year's total of 1,212 cases for this group of mammals. Cases of rabies reported in cats, dogs, horses and mules, and sheep and goats decreased 12.5%, 19.7%, 31.8%, and 16.7%, respectively, whereas cases reported in cattle increased 174%. In Puerto Rico, reported cases of rabies in mongooses decreased 4.1% and rabies in dogs (9 cases) remained unchanged from those reported in 2003. Among the 8 cases of rabies in human beings, 1 person from Oklahoma and 3 from Texas died following receipt of infected organs and tissues from an Arkansas donor. In California, a person originally from El Salvador and, in Florida, a person originally from Haiti both died of canine rabies infections acquired outside the United States. In Wisconsin, a teenager contracted rabies from a bat bite and became the first known person to survive rabies despite not having received rabies vaccine prior to symptom onset.

Rabies surveillance in the United States during 2003

During 2003, 49 states and Puerto Rico reported 7,170 cases of rabies in nonhuman animals and 3 cases in human beings to the CDC. This represents a 10% decrease from the 7,967 cases in nonhuman animals and 3 cases in human beings reported in 2002. More than 91 (n = 6,556) were in wild animals, and 8.6% (614) were in domestic species (compared with 92.5% in wild animals and 74% in domestic species in 2002). The relative contributions of the major groups of animals were as follows: 2,635 raccoons (36.7%), 2,112 skunks (29.4%), 1,212 bats (16.9%), 456 foxes (6.4%), 321 cats (4.5%), 117 dogs (1.6%), and 98 cattle (1.4%). Compared with cases reported in 2002, the number of cases reported in 2003 decreased among all reporting groups with the exception of cats, dogs, equids, and swine. Ten of the 19 states with enzootic rabies in raccoons, the District of Columbia, and New York City reported decreases in the numbers of rabid raccoons during 2003. Tennessee reported 4 cases of indigenous rabies in raccoons during 2003, becoming the 20th state where rabies in raccoons is known to be enzootic. On a national level, the number of rabies cases in skunks during 2003 decreased by 13.2% from those reported in 2002. Texas again reported the greatest number (n = 620) of rabid skunks during 2003, as well as the greatest overall state total of rabies cases (909). As in 2002, Texas did not report any cases of rabies associated with the dog/coyote variant of the rabies virus, but did report 61 cases associated with the gray fox variant of the virus (compared with 65 cases in 2002). The 1,212 cases of rabies reported in bats during 2003 represented a decline of nearly 12% from the previous year's record high of 1,373 cases for this group of mammals. Cases of rabies reported in foxes.and raccoons declined 10.2% and 8.9%, respectively, during 2003. Rabies among sheep and goats decreased from 15 cases in 2002 to 12 cases in 2003, whereas cases reported in cats, dogs, and equids increased 74%, 18.2%, and 8.6%, respectively. In Puerto Rico, reported cases of rabies in mongooses and dogs decreased 26.9% and 35.7%, respectively, from those reported in 2002. Three cases of rabies in human beings were reported in California, Virginia, and Puerto Rico during 2003. The Virginia case was the first reported occurrence of rabies in a human being infected with the raccoon rabies virus variant; however, the exposure history was unknown. The California and Puerto Rico cases were the result of infections with bat and dog/mongoose rabies virus variants, respectively, and each patient had a history of a bite.

Efficacy of cidofovir in a murine model of disseminated progressive vaccinia

An animal model that mimics progressive disseminated vaccinia was elaborated. To this end nude (athymic) mice were inoculated intracutaneously with vaccinia virus in the lumbosacral area. Viral replication (DNA) in the skin was detected as early as day 2 postinfection (p.i.). Mice developed typical vaccinia lesions at the site of inoculation by day 4 to 6 p.i. By about 2 weeks p.i., the infection had spread all over the body, a situation reminiscent of disseminated vaccinia in humans. The infection resulted in viremia and spread of the virus to visceral organs, as well as to the brain. Topical treatment with cidofovir, initiated at the day of infection or at day 1 p.i., completely protected against virus-induced cutaneous lesions and against associated mortality. When treatment was initiated at a later time (day 2 to 5 p.i.), a partial but marked protective effect was noted, which can be explained by the fact that by that time, the virus had spread from the skin to the visceral organs. Next, infected animals were left untreated until the time ( approximately 2 weeks p.i.) at which disseminated vaccinia had developed. When systemic treatment with cidofovir was initiated at that time, it caused lesions to heal and regress. In most of these animals, lesions had completely (or almost completely) disappeared by day 10 to 15 after the start of therapy. The observation that cidofovir is able to cause healing of disseminated vaccinia lesions in animals should have implications for the therapy of complications of vaccination against smallpox.

Intravenous immunoglobulin products contain neutralizing antibodies to vaccinia

BACKGROUND AND OBJECTIVES

Individuals with primary or secondary immune-deficiency diseases may be at risk for vaccinia infection if widespread smallpox-immunization programmes are implemented in the United States of America (USA) for bioterrorism preparedness. The objective of this study was to determine whether commercial immune globulin (intravenous, human) products contain biologically active antibodies to vaccinia that have the potential to protect people, with immune deficiencies, from complications of vaccinia.

MATERIALS AND METHODS

Eight currently United States (US)-licensed and two European intravenous immunoglobulin (IVIG) products were tested in a vaccinia plaque-reduction neutralization assay. The in vivo activity of five of these lots was assessed in severely immune-deficient mice.

RESULTS

All tested products contained neutralizing anti-vaccinia activity, in vitro and in vivo.

CONCLUSIONS

The use of IVIG by individuals with inherited or acquired humoral immune deficiencies may provide some protection if they are inadvertently exposed to vaccinia.

Rabies surveillance in the United States during 2002

During 2002, 49 states and Puerto Rico reported 7,967 cases of rabies in nonhuman animals and 3 cases in human beings to the Centers for Disease Control and Prevention, an increase of 7.2% from the 7,436 cases in non-human animals and 1 case in a human being reported in 2001. More than 92% (7,375 cases) were in wild animals, whereas 7.4% (592) were in domestic species (compared with 93.3% in wild animals and 6.7% in domestic species in 2001). Compared with cases reported in 2001, the numbers of cases reported in 2002 increased among all major reporting groups with the exception of swine and rodents and lagomorphs. The relative contributions of the major groups of animals were as follows: raccoons (36.3%; 2,891 cases), skunks (30.5%; 2,433), bats (17.2%; 1,373), foxes (6.4%; 508), cats (3.8%; 299), dogs (1.2%; 99), and cattle (1.5%; 116). Thirteen of the 19 states in which the raccoon-associated variant of the rabies virus has been enzootic reported increases in the numbers of rabid raccoons during 2002. Among those states that have engaged in wildlife rabies control programs, Ohio reported 1 case of raccoon rabies associated with the epizootic of rabies in raccoons and 1 case in an equid that was infected with a bat variant of the rabies virus, compared with 2 cases reported in terrestrial animals during 2001. Texas reported no cases of rabies associated with the dog/coyote variant of the rabies virus (compared with 1 case in 2001) and 65 cases associated with the gray fox variant of the virus (an increase of 225% from 20 cases reported in 2001). In Massachusetts and Rhode Island, states with enzootic raccoon rabies, reports of rabid skunks again exceeded those of rabid raccoons (the sixth consecutive year, although in Rhode Island, this difference decreased to only 7 more skunks than raccoons [38/31]). Tennessee reported a single case of raccoon rabies in a pet raccoon from the central part of the state; the captive animal had been transported toTennessee from northern Georgia. Nationally, the number of rabies cases in skunks during 2002 increased by 6.6% over those reported in 2001. Texas reported the greatest number (740) of rabid skunks and the greatest overall state total of rabies cases (1,049) during 2002. The 1,373 cases of rabies reported in bats during 2002 surpassed the previous year's record (1,281 cases) as the largest number of reported cases ever recorded for this group of mammals. Cases of rabies reported in cats (299), cattle (116), and dogs (99) increased by 10.7%, 41.5%, and 11.24%, respectively, from 2001 to 2002. Rabies among sheep and goats increased 400% from 3 cases in 2001 to 15 in 2002, and cases among horses and mules increased 13.7% (51 cases in 2001 to 58 in 2002). Reported cases of rabies in mongooses in Puerto Rico decreased 4.3% from the previous year (70 cases in 2001 to 67 cases in 2002), while cases of rabies in dogs increased 77% (13 to 14). California, Tennessee, and Iowa each reported a case of rabies in a human being during 2002. All cases of rabies in humans were the result of infection with bat variants of the rabies virus.

Pathogenesis and potential antiviral therapy of complications of smallpox vaccination

Vaccination against smallpox may result in a variety of complications, ranging in severity from benign to lethal. Universal vaccination was halted in the US in 1972, so almost half the present population has never been vaccinated. Because side effects occur most often in first-time vaccinees, current plans for rapid large-scale vaccination in the event of bioterrorist attack raise concerns about the occurrence of a large number of adverse events. Most complications result from the excessive replication of vaccinia virus, making them potential targets for antiviral therapy. Effective treatment is especially needed for persons with atopic dermatitis or eczema, who are unusually susceptible to the initiation and spread of vaccinia infection because of defects of innate immunity in the skin, and for individuals with defective cell-mediated immunity, who are unable to eliminate vaccinia infection once it has begun. In the past, many complications were treated with vaccinia immune globulin (VIG) and/or the antiviral drug methisazone, but neither was tested in placebo-controlled trials. New antiviral drugs are now available, but have not yet been evaluated for treating vaccinia infections in humans. Both laboratory research and clinical studies are needed to help prevent serious complications in any major vaccination campaign.

Progressive vaccinia

The resumption of smallpox vaccination for health care workers and other first responders has raised concern about the occurrence of complications in people with immunodeficiency disorders, including those infected with human immunodeficiency virus. During the era of universal vaccination, roughly 1 person per million vaccinees in the general population developed progressive vaccinia, which is characterized by the relentless outward spread of infection from the vaccination site and eventual dissemination to other areas on the body. Review of 56 cases reported in the English-language medical literature from 1893 through 1997 indicates that the condition occurred only in persons with severe cell-mediated immunodeficiency. Progressive vaccinia was found to be lethal in infants who completely lacked cellular immune function, but infection resolved in many adults with acquired immunodeficiency. Almost all cases were treated with vaccinia immune globulin, but its efficacy has never been tested in a placebo-controlled trial. Further research is needed to develop effective forms of therapy.

Rabies surveillance in the United States during 2001

During 2001, 49 states and Puerto Rico reported 7,437 cases of rabies in nonhuman animals and 1 case in a human being to the Centers for Disease Control and Prevention, an increase of < 1% from 7,364 cases in nonhuman animals and 5 human cases reported in 2000. More than 93% (6,939 cases) were in wild animals, whereas 6.7% (497 cases) were in domestic species (compared with 93.0% in wild animals and 6.9% in domestic species in 2000). The number of cases reported in 2001 increased among bats, cats, skunks, rodents/lagomorphs, and swine and decreased among dogs, cattle, foxes, horses/mules, raccoons, and sheep/goats. The relative contributions of the major groups of animals were as follows: raccoons (37.2%; 2,767 cases), skunks (30.7%; 2,282), bats (17.2%; 1,281), foxes (5.9%; 437), cats (3.6%; 270), dogs (1.2%; 89), and cattle (1.1%; 82). Nine of the 19 states where the raccoon-associated variant of the rabies virus has been enzootic reported decreases in the numbers of rabid raccoons during 2001. Among states with extensive wildlife rabies control programs, Ohio reported (other than rabies in bats) 1 case of rabies in a raccoon that was associated with the epizootic of rabies in raccoons and 1 case in a bovid that was infected with a bat variant of the rabies virus, compared with no cases reported in any terrestrial animals during 2000. Texas reported 1 case associated with the dog/coyote variant of the rabies virus (compared with no cases in 2000) and 20 cases associated with the gray fox variant of the virus (a decrease of 50% from reported cases in 2000). Reports of rabid skunks in Massachusetts and Rhode Island, states with enzootic raccoon rabies, exceeded reports of rabid raccoons for the fifth consecutive year. A similar situation may soon exist in the state of Maine (32 rabid skunks and 34 rabid raccoons during 2001). Nationally, the number of rabies cases in skunks during 2001 increased by 2.7% over those reported in 2000. Texas reported the greatest number of rabid skunks ever documented during a single year by any state, as well as the greatest numerical increase in rabid skunks (778 cases in 2001, compared with 550 in 2000; an increase of 228 cases, or 41.5%) and the largest overall state total of rabies cases (1,043) during 2001. Arizona reported the greatest percentage increase in rabid skunks (247.1%), representing an increase from 17 rabid skunks in 2000 to 59 in 2001. Nineteen of these cases were infected with a bat variant of the rabies virus, documenting a spillover event followed by unprecedented detection of temporal enzootic transmission of a bat variant in a terrestrial species. The number of cases of rabies reported in bats during 2001 (1,281 cases) increased 3.3% and surpassed the previous year's record (1,240 cases) as the largest number of reported cases ever recorded for this group of mammals. Cases of rabies reported in dogs (89) and cattle (82) decreased by 21.9 and 1.2%, respectively; these are the lowest numbers reported for rabid cattle and dogs since the dawn of national rabies record keeping (ca 1938). Cases in cats (270) increased by 8.4% over those reported in 2000, whereas rabies among sheep and goats declined 70%, from 10 cases in 2000 to 3 cases (goats only) in 2001. Rabies among horses and mules declined 1.9% (52 cases in 2000 to 51 cases in 2001). Reported cases of rabies in mongooses in Puerto Rico increased 18.6%, compared with the previous year (70 cases in 2001 from 59 cases in 2000), whereas cases of rabies in dogs declined 15.3% (15 to 13). One case of rabies in a human being reported by California during 2001 was the result of infection with a canine variant of the rabies virus acquired outside the United States.

Rabies surveillance in the United States during 2000

During 2000, 49 states, the District of Columbia, and Puerto Rico reported 7,364 cases of rabies in nonhuman animals and 5 cases in human beings to the Centers for Disease Control and Prevention, an increase of 4.3% from 7,067 cases in nonhuman animals reported in 1999. Ninety-three percent (6,855 cases) were in wild animals, whereas 6.9% (509 cases) were in domestic species (compared wth 91.5% in wild animals and 8.5% in domestic species in 1999). Compared with cases reported in 1999, the number of cases reported in 2000 increased among bats, dogs, foxes, skunks, and sheep/goats and decreased among cats, cattle, horses/mules, raccoons, and swine. The relative contributions of the major groups of animals were as follows: raccoons (37.7%; 2,778 cases), skunks (30.2%; 2,223), bats (16.8%; 1,240), foxes (6.2%; 453), cats (3.4%; 249), dogs (1.6%; 114), and cattle (1.1%; 83). Ten of the 19 states where the raccoon-associated variant of the rabies virus has been enzootic reported increases in the numbers of cases of rabies during 2000. Among those states that have engaged in extensive wildlife rabies control programs, no cases of rabies associated with the epizootic of rabies in raccoons (or in any other terrestrial species) were reported in Ohio, compared with 6 cases reported in 1999. No rabies cases associated with the dog/coyote variant (compared with 10 cases in 1999, including 5 in dogs) were reported in Texas, and cases associated with the gray fox variant of the virus decreased (58 cases in 2000, including 38 among foxes). Reports of rabid skunks exceeded those of rabid raccoons in Massachusetts and Rhode Island, states with enzootic raccoon rabies, for the fourth consecutive year. Nationally, the number of rabies cases in skunks increased by 7.1% from that reported in 1999. The greatest numerical increase in rabid skunks (550 cases in 2000, compared with 192 in 1999) was reported in Texas. The number of cases of rabies reported in bats (1,240) during 2000 increased 25.4% over the number reported during 1999 (989) and represented the greatest contribution (16.8% of the total number of rabid animals) ever recorded for this group of mammals. Cases of rabies reported in cattle (83) and cats (249) decreased by 38.5% and 10.4%, respectively, whereas cases in dogs (114) increased by 2.7% over those reported in 1999. Reported cases of rabies among horses and mules declined 20% from 65 cases in 1999 to 52 cases in 2000. Four indigenously acquired cases of rabies reported in human beings were caused by variants of the rabies virus associated with bats. One case of human rabies acquired outside the United States that resulted from a dog bite was caused by the canine variant of the rabies virus.

Rabies surveillance in the United States during 1999

During 1999, 49 states, the District of Columbia, and Puerto Rico reported 7,067 cases of rabies in nonhuman animals to the Centers for Disease Control and Prevention, a decrease of 11.2% from 7,961 cases in nonhuman animals and 1 case in a human being reported in 1998. More than 91% (6,466 cases) were in wild animals, whereas 8.5% (601 cases) were in domestic species (compared with 92.4% in wild animals and 7.6% in domestic species in 1998). No cases of rabies were reported in human beings in 1999. Decreases were evident in all major species groups, with the exception of cattle, sheep/goats, and swine. The relative contributions of the major groups to the total reported were as follows: raccoons (41.0%; 2,872 cases), skunks (29.4%; 2,076), bats (14.0%; 989), foxes (5.4%; 384), cats (3.9%; 278), cattle (1.9%; 135), and dogs (1.6%; 111). Reported cases (6) associated with the epizootic of rabies in raccoons in Ohio declined from the 26 cases reported in 1998. Fifteen of the 19 states where the raccoon variant of the rabies virus is enzootic reported fewer cases of rabies during 1999. Massachusetts and Rhode Island, states with enzootic rabies in raccoons, each reported more rabid skunks than rabid raccoons for the third consecutive year. In Texas, cases associated with the enzootic canine variants of the rabies virus remained low (10 cases), whereas cases associated with the gray fox variant of the virus increased (66). Cases of rabies in skunks decreased by 8.6%, compared with those reported in 1998. Michigan reported the largest percentage increase in rabid skunks (950.0%; 2 cases in 1998 to 21 in 1999). Cases of rabies in horses and mules declined 21%, from 82 cases in 1998 to 65 in 1999. Cases of rabies reported in bats (989) were similar in number to those reported in 1998 (992) and represented almost 14.0% of the total number of rabid animals reported during 1999. Reported cases of rabies in cats (278) and dogs (111) decreased by 1.4% and 1.8%, respectively, whereas cases in cattle (135) increased by 16.4%, compared with those reported in 1998.

Epidemiology and elimination of rabies in western Europe

In recent years, most of the research on the control of sylvatic rabies has concentrated on developing methods of oral vaccination of wild rabies vectors. In order to improve both the safety and the stability of the vaccine used, a recombinant vaccinia virus, which expresses the immunizing glycoprotein of rabies virus (VRG), has been developed and extensively tested in the laboratory as well as in the field. Between 1989 and 1995, several million VRG vaccine doses have been dispersed in Western Europe for the vaccination of red foxes, leading to the elimination of sylvatic rabies from large areas, which have consequently been freed from the need for vaccination. This approach may have consequences for the regulation of pet movement within the whole European Union.