What Are the New Findings?

In 2016, the U.S. Army Medical Department Activity-Bavaria recorded 108 possible rabies exposures, a 112% increase from the previous year. Of these, 49 (45%) occurred during prior deployments to Egypt and Eastern Europe in which they had not received timely rabies post-exposure prophylaxis.

What Is the Impact on Readiness and Force Health Protection?

Military members are at risk for rabies exposure because of personal and military travel and deployments to rabies endemic areas. In order to avoid a repeat of the rabies fatalities of the past, commanders must enforce General Order #1 which calls for avoidance of contact with local animals, including mascots and pets.

Following the death of a soldier from rabies in 2011, linked to exposure to rabies in Afghanistan,¹ the U.S. military implemented enhanced active surveillance of animal exposures to prevent rabies in service members and other Military Health System beneficiaries.² Because many exposures were related to deployment to Iraq or Afghanistan, the Department of Defense (DOD) added questions about animal exposure to post-deployment health assessments to improve the detection of possible rabies exposures. Exposures identified through post-deployment health assessments as well as exposures documented through local military health care or law enforcement reports are collected by military public health personnel.

Although Germany is rabies-free for terrestrial land mammals,³ rabies exposure remains a concern for U.S. military personnel assigned there because of personal and military travel and deployments to rabies endemic countries. Since 2011, however, the number of service members deploying to Southwest Asia has greatly declined; as a result, deployments have become much more variable both in location and duration. Deployments have increasingly focused on enhancing partnerships and peacekeeping. For example, U.S. soldiers stationed in Germany have been involved in partnering missions with European allies and UN peacekeeping operations in the Sinai region of Egypt.⁴ In 2016, U.S. Army Medical Department Activity-Bavaria (MEDDAC-B) Preventive Medicine (PM) personnel suspected an increase in the risk of rabies exposure for soldiers deployed in support of the Sinai peacekeeping mission. This report describes efforts that were undertaken to investigate this possible increased risk of rabies exposure faced by service members.

Methods

For purposes of this report, the term "exposure" refers to all instances of human contact with animals, including bites, contact with animal saliva, scratches, or casual contact, which came to medical attention and were evaluated for the potential that the patient might have been exposed to rabies virus. The U.S. Army Medical Department Activity Bavaria (MEDDAC-B) provides public health support to all U.S. military and affiliated personnel stationed in southern Germany. For such personnel, all reported exposures, independent of location, are reviewed by PM and Veterinary personnel to ensure appropriate care and follow-up. Decisions about whether to initiate rabies post-exposure prophylaxis (RPEP) are made on the basis of the risk of the exposure. Such assessments consider the type of animal, the geographic location of the exposure event, and the immunization status of the animal. In general, exposures are reported per DOD Policy using DOD Form 2341, Report of Animal Bite– Potential Rabies Exposure (DD Form 2341);⁵ however, some exposures were reported through other channels, such as email, phone call, or Military Police Report forwarded to MEDDAC-B PM. In those cases, a DD Form 2341 is completed by the treating or evaluating medical facility to which the patient is assigned and referred (if needed). The DD Form 2341 captures information on patient demographics and consists of four parts: animal bite history, management of animal bite case, management of biting animal, and case review. The biting animal is handled in accordance with the Compendium of Animal Rabies Prevention and Control; for dogs and cats (the vast majority of exposures considered here), the animal is observed for 10 days from the time of exposure for the development of signs consistent with rabies, if possible. For unwanted/stray animals, euthanasia for testing of the brain was an option, though to the best of our knowledge this was not carried out.⁶

In cases where prophylaxis is clearly indicated (such as exposure to bats or bite from a stray dog in a non-rabies-free area), prophylaxis is initiated by the evaluating provider and then reported to MEDDAC-B PM as part of information collected on DD Form 2341. If there is any question about whether prophylaxis is indicated, the evaluating provider can contact MEDDAC B PM for discussion and consultation. Upon receipt of DD 2341, MEDDAC-B PM reviews the prophylaxis given, if any. If further prophylaxis (including RPEP) is indicated, MEDDAC-B PM immediately contacts the treating provider to discuss this. The exposure and prophylaxis, as recorded on DD Form 2341, are concurrently reviewed by a local veterinarian. After any additional prophylaxis and veterinary review, the MEDDAC-B PM physician again reviews the case and is the final signatory. Under normal circumstances, potential exposures (and attendant DD Form 2341) are reviewed concurrently with periodic in-person meetings between all involved (Rabies Advisory Board) to review cases. In response to the concerns described above, in 2016 the Rabies Advisory Board increased the frequency of its meetings, and included leadership from the units of the deployed soldiers, staff from the treating clinic, and others as appropriate.

Since mid-2011, MEDDAC-B personnel have recorded details of exposures to assure appropriate and timely follow up and have documented rabies post-exposure prophylaxis when indicated. The number of individuals affected by possible rabies exposures and the number of individuals who received RPEP in 2016 were compared to data from 2011–2015 and 2017. In addition, details from the 2016 exposures were extracted, including age, sex, military status, animal type, location and exposure type. All exposures reported to MEDDACB PM or Veterinary Section through the means described above were included in the study. Exposures were included independent of the final determination of risk for transmission of rabies or the status of the victim (U.S. Military or Civilian, German National, or citizen from other country); however, because most exposure reports were initiated at U.S. military health clinics, these data represent primarily individuals who had access to health care in such clinics in southern Germany.

Investigation

In response to the suspected increase in rabies exposures in 2016, several actions were immediately undertaken. PM and Veterinary assets in Bavaria began closely coordinating follow-up and risk stratification of reported exposures, especially those from Egypt. Veterinary personnel coordinated directly with personnel stationed in Egypt to identify the names, appearance (through photos) and locations of all approved NATO mascot dogs in Egypt. These data were discussed with individual soldiers reporting possible exposure upon return from deployment. Prophylaxis and follow-up efforts, where indicated, were closely coordinated with the local clinic and the unit medical assets (Regimental Surgeon) of the unit to which the soldiers were assigned. All soldiers started on RPEP were followed up for prophylaxis completion, even those who moved back to the U.S. or deployed again.

Results

Among service members and other persons (e.g., family members, civilian employees) located in southern Germany in 2016, 108 individuals were associated with reports of possible rabies exposure. Numbers of individuals with possible rabies exposures and the numbers and percentages who received RPEP by year (2011–2017) are presented in Table 1. In 2016, compared to prior years, there was a notable increase in the numbers of individuals evaluated in southern Germany for possible exposure to rabies (Table 1). Moreover, in 2016, compared to the previous 5 years, a larger proportion of exposed individuals were prescribed rabies post-exposure prophylaxis (RPEP). In 2017, the number of exposures reported was much closer to historical numbers in the years 2011–2015.

Characteristics of the individuals with possible rabies exposures in 2016 are presented in Table 2. Most exposures occurred in individuals who were active duty service members, male, those aged 18–29 years, and junior (E1–E4) or senior (E5–E7) enlisted service members. Many exposures (47.2%) occurred outside of Germany (Egypt or Eastern Europe). The animals most commonly implicated in the exposures were stray/feral cats or dogs or other wild animals and the most common exposure type was animal bite.

Editorial Comment

Several factors appeared to be related to the 2016 increase in possible rabies exposures. First, a large number of soldiers was assigned to United Nations (UN) peacekeeping operations in Egypt during 2016. Of the years considered, only in 2016 were a large number of troops supported by MEDDAC-B deployed to Egypt. In Egypt, UN camp policies permitted mascot dogs. Many soldiers brought onto their base camps non-approved/informal mascots (cats and dogs). Approved mascots received complete and ongoing preventive veterinary care (including rabies vaccine). Some non-approved/informal mascots were captured in a trap-neuter-release program (spayed/neutered and provided a single dose of rabies vaccine) while other non-approved mascots received no such care. This situation led to the common misperception that interaction with any animal on the base was permissible and safe (i.e., many soldiers believed that all animals had been fully immunized against rabies). Only through retrospective discussion with veterinary staff in Egypt was it discovered that most animals on base were unprotected from rabies. This misperception among soldiers about the status of an animal (unclear if mascot or stray) was a very significant, and likely preventable, cause of the increased number of exposures seen in 2016.

Second, exposures from foxes or other (unidentified) wild animals occurred in a forested training area in Germany. Although Germany is rabies-free for terrestrial mammals, these exposures were determined to be of sufficient risk to merit prophylaxis, given the close proximity of the training areas to the border of the Czech Republic where rabies is present in bats.⁷ These exposures from foxes/wild animals in the training area occurred at an increased level in 2016, compared to other years. Finally, some U.S. soldiers who were in Eastern Europe (i.e., outside Germany) for partnership building and training events were exposed to stray animals with unknown immunization status. Of note, there were no local policy changes, new leadership or meaningful demographic changes in the MEDDAC-B supported population in 2016 that might have resulted in increased rabies reports.

U.S. combat operations in Iraq and Afghanistan have diminished, but peacekeeping and partnership building missions continue. The characteristics of U.S. military deployments have changed, becoming generally shorter, more frequent, and to a much broader range of destinations; accordingly, the potential for rabies exposure is more variable and difficult to predict. As years pass since the last rabies case and as the nature of deployments changes, the U.S. military faces the risk of again underappreciating the threat from this highly lethal virus.⁸ The findings presented here suggest a need for accurate risk assessment with clear risk communication⁹ and ongoing robust surveillance with strong command engagement in preventing service member contact with possibly rabid animals.¹⁰

Author affiliations: U.S. Army Medical Department Activity–Bavaria (Dr. Mease, Ms. Whitman); Bavaria Veterinary Services, Public Health Activity Rheinland-Pfalz (Dr. Lawrence); Guantanamo Bay Veterinary Services, Public Health Activity–Fort Gordon, GA (Dr. Lawrence).

Acknowledgments: The authors thank Catrina Caswell, LPN; Daniel Weinstein, DO (MAJ, MC, USA); and Justin Garner (SSG, USA) for providing outstanding support and teamwork.

Funding: All work described herein was performed as part of paid regular duties as part of employment by the U.S. Government.

Conflicts of interest: None.

References

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