An oddly behaving calf bitten by a skunk. A dog chewing its way out of the chain-link kennel. A cat bloodied from a fight with a raccoon. Veterinarians don’t easily forget their rabid, infectious patients, and consider them an occupational hazard.

But although rabies is nearly 100-percent fatal to humans, many veterinarians admit that they may not be fully protected against the disease, and that their technicians and other employees may not be protected at all.
 
“Vets do such a good job at proactive preventive health measures by vaccinating dogs and cats against rabies to protect the public health, but we are not proactive about vaccinating ourselves for rabies, and we are at the front lines,” said Dr. Brett Cordes, veterinary medical director of animal health at The Apothecary Shops, a specialty pharmacy chain with headquarters in Phoenix. “We are not practicing what we preach.”

The problem, veterinarians argue, is that the pre-exposure vaccine for people is prohibitively expensive, subject to supply shortages or otherwise difficult to find and not always covered by insurance.

At the same time, they acknowledge that vaccination after exposure to rabies is far costlier, particularly if it’s required for several members of a veterinary clinic staff at one time. Pre-exposure vaccination costs about $750 for a series of three doses; post-exposure vaccination requires four doses plus immune globulin, which can run thousands of dollars.

The U.S. Centers for Disease Control and Prevention (CDC) reported four human cases of rabies in 2009 and 6,690 rabid animals in 49 states and Puerto Rico. The statistics leave no ambiguity about the risk of rabies and the need for protection for veterinarians and other clinic employees.

The Advisory Committee on Immunization Practices, which develops vaccination recommendations for the CDC, states that pre-exposure vaccination should be considered “for persons whose activities bring them into frequent contact with rabies virus or potentially rabid animals, such as veterinarians and their staff, animal handlers, rabies researchers, and certain laboratory workers.”

The CDC specifies that veterinarians and their staff in “rabies enzootic areas” should have a serum sample tested for rabies antibody every two years and get a booster dose of vaccine if the titer is less than complete neutralization at a 1:5 serum dilution.

Although most veterinarians have been vaccinated by the time they graduate from veterinary school, many do not keep up with titer testing and boosters as their careers progress.

A study by the CDC in collaboration with the American Veterinary Medical Association (AVMA), “Infection control practices and zoonotic disease risks among veterinarians in the United States,” published June 15, 2008, in the AVMA journal JAVMA, confirmed the lax attention to rabies infection prevention.

The study found that fewer than 25 percent of veterinarians with prior rabies vaccination had their serum anti-rabies-virus antibody titer checked within the past two years.

Rabies vaccination rates among veterinary technicians and other non-veterinarian clinic employees are unknown. But interviews with several veterinarians suggest that vaccinations for workers who come in contact with patients generally is not a priority.

AVMA spokesman Michael San Filippo said in an e-mail that the organization “believes that all veterinary personnel should be offered pre-exposure vaccination,” but did not specify who should cover the cost. At its national and statewide meetings, the organization has offered rabies titer testing and vaccination at discounted rates.

At Banfield Pet Hospital, the largest veterinary hospital owner in the country with 766 clinics, rabies immunization is strongly recommended but not mandatory for hospital employees. Rabies prophylaxis is a covered expense under Banfield’s group health plan, according to the company.

In 2007, an unvaccinated dog from an area known as Skunk Alley that presented "peculiar behavior and vomiting" was brought by his owner to Dr. Melanie Moore of Concord, N.C., for evaluation. Although the dog’s illness didn’t look like a textbook case of rabies and the dog hadn’t bitten anyone, Moore followed her instinct. She kept the animal at the hospital for observation.

“When I took it to the kennel, the dog went berserk and tried to eat his way through the chain link door,” she said in an interview. “He tore his mouth and broke his teeth, and now we had people standing there that got blood and saliva in their faces.”

In an account Moore posted at the time on the Veterinary Information Network (VIN), an online community for the profession, she told of watching the dog for an hour, then calling her state epidemiologist for permission to test for rabies. The owner agreed to euthanize the dog so he could be tested, Moore said.

Four days later, the test results confirmed the rabies diagnosis. As a result, Moore needed a post-exposure vaccine booster for herself; four others in her clinic had to have the full post-exposure vaccination regimen. Fortunately, Moore’s health insurance covered the booster, and her worker’s compensation policy covered shots for her staffers. Unfortunately, the worker’s compensation company later refused to renew her policy because of the costly claims, Moore said.

According to the May 23, 2008, issue of Mortality and Morbidity Weekly Report published by the CDC, somewhere between 16,000 and 39,000 people come in contact with potentially rabid animals and receive rabies post-exposure prophylaxis each year.

The same analysis assumed that the direct medical costs associated with post-exposure prophylaxis included one dose of human rabies immune globulin ($326 to $1,434), five doses of the rabies vaccine ($113 to $679 each), hospital charges ($289 to $624), and physician charges ($295 to $641).

Today, Moore says that she and only one of her technicians are fully protected against rabies. She acknowledges that the rest of her staff should get the pre-exposure vaccination, but that it is too costly for her to cover everyone, and most of her employees probably couldn’t afford it on their own.

“It’s hard to get. It’s expensive. It’s a big investment,” she said. “But I am thinking I need to bite the bullet and do it.”

Dr. Becky Lundgren, who practiced in Kansas from 1977 until 2002 and now works for VIN, said that in years past, veterinarians easily could obtain a vaccination from a private physician. They also could order vaccine directly from the manufacturer, Lundgren said, and have the vaccination administered by the local health department or in a doctor’s office or even give themselves the shots.

But today, veterinarians tell her that it is harder to find a physician who will order it. She suspects the reasons are manifold: doctors may be reluctant to use a vaccine with which they have little experience; the cost of the vaccine has gone up and minimum orders are required (so any product left unused will cost them money); and, in today's litigious environment, physicians may be concerned about lawsuits resulting from adverse reactions to the vaccine.

Novartis, maker of RabAvert, one of two human rabies vaccines available in the United States, declined to comment about the vaccine’s cost, except to note that both pre- and post-exposure regimens require multiple doses. A company spokeswoman, in an e-mail, pointed out that Novartis offers a patient assistance program for post-exposure vaccination, and that it is working on a pilot program to increase veterinary access to the vaccine.

Cordes, the pharmacy veterinary medical director in Arizona, has worked with Novartis and the AVMA to offer discount vaccination clinics at veterinary conferences. He said he hopes to expand the program to get more people in the profession immunized against rabies.

Sanofi Pasteur also manufactures the vaccine. A company spokesman did not provide answers immediately to questions from the VIN News Service.

Cordes said he suspects that manufacturers can sell the human rabies vaccine at a premium because it’s a narrow-focus product with relatively few sales.

For personnel needing protection, the cost of about $750 for pre-exposure immunization is prohibitive, he said: “For the young people in vet tech schools, that’s a problem. And for a vet, when they have 10 employees and none are vaccinated, that’s 30 shots and $7,500.”

Dr. Joanna McCoy, a practice owner in Maryland, said she would like all of her clinic staff to be vaccinated, including the receptionist. But because of the expense, she decided to pay for vaccinations only for those employees who have worked in the clinic for at least three years. And while her employee handbook states that employees must be vaccinated within 12 months of employment, she acknowledged that she does not enforce the requirement.

“Most of them will wait (the three years),” she said. “They are not highly paid enough to afford it on their own.”

McCoy favors mandatory rabies vaccination for veterinary clinic staff, reasoning that greater demand would drive down prices.

Dr. Kelly Cooper was an associate in a New York clinic when three-quarters of the employees came in contact with a rabid cat brought in for treatment. All had to undergo the post-exposure vaccination regimen. Fortunately, Cooper said, New York law requires county public health departments to pay for it, so the clinic costs were minimal.

Cooper favors mandatory rabies vaccination for people at high risk, as well as mandatory health insurance coverage of the vaccine. Now a clinic owner, she said she has not been able to cover immunizations for her two employees, but plans to provide vaccinations as a benefit as soon as it is financially feasible.

“There are rabies clinics for dogs and cats that are low-cost,” she said. “I think it should at least be subsidized for people at high risk of infection such as highway workers, animal caretakers, shelter personnel, animal control officers and veterinary personnel.”

The AVMA, which insures many veterinarians through its Group Health and Life Insurance Trust, offers a basic protection package for veterinarians and their families that pays $600 toward rabies prophylaxis given either before or after exposure.

For others the picture is less clear. An online forum on the subject at the Student Doctor Network included nearly 50 comments from veterinary students looking for answers about rabies vaccine coverage. Some said their private health insurance covered the cost; others said theirs would not. Some said their schools would offer the shots for free. Others paid for vaccinations at their local health departments.

Dr. Radford Davis, associate professor of public health in the Department of Veterinary Microbiology and Preventive Medicine at Iowa State University, said regardless of the cost and in light of the risk, veterinarians and clinic owners have an obligation to protect the health of their employees, including the technicians. If they don’t, he said, they may be held liable.

“I tell my students that vaccinating your employees for rabies shows that you have an investment in them, that you want to protect them but also (that) you want them to be successful,” Davis said.