A Rabid Dog Imported From Egypt: Kansas, 2019, and the Risk of Faked Vaccine Papers

Summary

• Canine rabies — the dog strain of the virus — was eliminated from the United States after roughly six decades of vaccination, licensing and stray-dog control. But dogs are still the main source of human rabies worldwide, and dogs imported from high-risk countries could bring the strain back.
• In 2019, one of 26 rescue dogs imported into Kansas from Egypt had rabies, even though every dog arrived with a rabies vaccination certificate, a veterinary inspection certificate, and papers from an Egyptian laboratory showing an immune response.
• U.S. blood testing showed that most of the dogs had never been vaccinated. Why the rabid dog's vaccination failed is unknown.
• Vaccination records for dogs from high-risk countries should be checked critically before the dogs enter the United States, and public health officials consulted when papers look questionable.

The dogs' journey

Dogs entering the United States from about 100 countries where canine rabies is endemic, Egypt among them, need a rabies vaccination certificate. On January 28, 2019, 26 dogs landed at Pearson International Airport in Toronto from Cairo. A pet rescue organization in the Kansas City area drove them into the United States through Port Huron, Michigan. Canadian authorities, the U.S. Border Patrol and the Kansas Department of Agriculture reviewed their papers, which met the entry rules, and the dogs were adopted or fostered in Kansas and Missouri right away.

The sick dog

On February 20, a 2-year-old fostered dog ("dog A") began drinking and eating excessively and had diarrhea. The next evening it vomited, swallowed a blanket, and grew unsteady, drooling and vocalizing abnormally.

• February 21: at veterinary hospital A, it turned abnormally aggressive and bit a technician.
• February 22–23: at hospital B, its third eyelids protruded on both sides and it began snapping at the air as if catching flies — both neurological signs consistent with rabies. It could no longer stand and grew more aggressive.
• February 24: staff suspected rabies; the dog was humanely euthanized and sent for testing.
• February 25: the Kansas State University Rabies Laboratory confirmed rabies, the third imported rabies case in a dog from Egypt in 4 years.
• March 1: CDC sequencing identified the cosmopolitan canine rabies lineage that circulates in Egypt — 99.5% identical (six nucleotide differences) to the virus from a rabid dog imported into Connecticut from Egypt in 2017.

Protecting people

State, county and federal health and agriculture agencies worked together, interviewing the dog's caretakers, the rescue's director and staff at both hospitals.

• 44 people chose to start post-exposure rabies shots; 38 (86%) were veterinary staff who began before public health had assessed them.
• After assessment, health officials recommended the shots for only 19: 13 veterinary staff, five rescue employees and one household contact. 18 of the 19 (95%) had been exposed without a bite.

Protecting other animals

• Dog A had been fostered with 12 other dogs and two cats. Two of those dogs were unvaccinated — one had been pregnant when the rescue took it in, the other for unknown reasons — and were quarantined for 6 months. The other 10 got rabies boosters and were watched for 45 days. The cats were never exposed.
• Dog A's own blood showed neutralizing antibody (0.8 IU/mL) but no IgG (<0.125 EU/mL), meaning the antibody was the early IgM kind. Its vaccination was said to be more than two months old; a vaccinated dog would have long-lived IgG. So dog A had never been vaccinated and was in the early stage of rabies infection.
• Unsure whether the Egyptian papers or vaccines could be trusted, Kansas health officials required the other 25 dogs to be quarantined or euthanized. All 25 went back to the rescue, an approved facility, for quarantine by March 1.

Testing the others. The certificates named rabies vaccines from three manufacturers, and the lot numbers checked out. Quarantine length was set by prospective serologic monitoring: blood tests on day 0 and days 5–7, with a vaccine given after the first. A dog counts as previously vaccinated if the first result is at least 0.5 IU/mL, or if the result rises significantly (a 1.8-fold increase) to at least 0.5 IU/mL by the second test.

• Only 7 dogs showed evidence of earlier vaccination; they were quarantined 4 months.
• The other 18 showed none and needed 6 months.
• Counting from arrival on January 28, all were released on May 29 or July 29, 2019. Every dog survived, as did the other animals exposed at the foster home.

What it shows

• Volume: CDC estimates 1.06 million dogs enter the United States each year, 107,100 of them from areas at high risk for canine rabies — countries where the virus circulates anywhere and whose rabies surveillance and dog vaccination fall short of World Organisation for Animal Health standards.
• Cost: each imported case strains public health. A response is estimated to take 800 hours and nearly $214,000 in staff time and rabies shots. Here, the shots averaged $9,290 a person, excluding administration and exam fees — $176,510 for the 19 people advised to have them, or $408,760 for all 44 who did.
• Papers can't be taken on trust: federal rules require vaccination at least 28 days before travel, and Kansas requires a veterinary inspection certificate within 30 days of movement and rabies vaccination for animals over 3 months old. These papers were checked at two borders and the vaccine lots verified — yet only 7 of 25 dogs had actually responded to vaccination, though the Egyptian lab's tests said all had. The lab could not be reached to confirm its results: its contact details were invalid.
• A pattern: all three rabid dogs imported from Egypt in 4 years — to Connecticut, Virginia and Kansas — were rescue dogs with vaccination certificates. The Virginia dog's certificate had been deliberately falsified. Whether dog A's failure came from poorly stored vaccine, vaccine failure or fraudulent papers is unknown, but the other dogs' results point to a systemic failure: either vaccine was not being delivered properly, or documents were forged.

On May 10, 2019, CDC suspended dog imports from Egypt.

Sources

Based on Chelsea Raybern, Allison Zaldivar, Sheri Tubach and others, "Rabies in a Dog Imported from Egypt — Kansas, 2019," MMWR, Centers for Disease Control and Prevention; a work of the United States government in the public domain; rewritten in hubnx's own words. The report names the Missouri health department two ways; its name is the Department of Health and Senior Services.