Rabies-endemic Countries Research Articles

Establishment of a High Canine Rabies Burden in Haiti through the Implementation of a Novel Surveillance Program [corrected

The Republic of Haiti is one of only several countries in the Western Hemisphere in which canine rabies is still endemic. Estimation methods have predicted that 130 human deaths occur per year, yet existing surveillance mechanisms have detected few of these rabies cases. Likewise, canine rabies surveillance capacity has had only limited capacity, detecting only two rabid dogs per year, on average. In 2013, Haiti initiated a community-based animal rabies surveillance program comprised of two components: active community bite investigation and passive animal rabies investigation. From January 2013 –December 2014, 778 rabies suspect animals were reported for investigation. Rabies was laboratory-confirmed in 70 animals (9%) and an additional 36 cases were identified based on clinical diagnosis (5%), representing an 18-fold increase in reporting of rabid animals compared to the three years before the program was implemented. Dogs were the most frequent rabid animal (90%). Testing and observation ruled out rabies in 61% of animals investigated. A total of 639 bite victims were reported to the program and an additional 364 bite victims who had not sought medical care were identified during the course of investigations. Only 31% of people with likely rabies exposures had initiated rabies post-exposure prophylaxis prior to the investigation. Rabies is a neglected disease in-part due to a lack of surveillance and understanding about the burden. The surveillance methods employed by this program established a much higher burden of canine rabies in Haiti than previously recognized. The active, community-based bite investigations identified numerous additional rabies exposures and bite victims were referred for appropriate medical care, averting potential human rabies deaths. The use of community-based rabies surveillance programs such as HARSP should be considered in canine rabies endemic countries.

Global partnerships are critical to advance the control of Neglected Zoonotic Diseases: The case of the Global Alliance for Rabies Control

There is a need for innovation to improve control of all Neglected Zoonotic Diseases (NZDs). The Global Alliance for Rabies Control was formed to prevent human deaths from rabies and relieve the burden of rabies in other animal populations, especially dogs. It aims to identify reasons for the neglect of rabies in developing countries and to develop strategies to improve rabies control. Through initiatives such as World Rabies Day and the Partners for Rabies Prevention, progress has been made towards increased awareness of the burden of rabies transmitted by dogs at scales from local to international. An evidence base of the feasibility of canine rabies elimination has been built up and now easier access to information and tools enables countries to design and implement rabies elimination strategies in a logical way, utilizing the structures of regional networks for rabies control. The body of evidence has built consensus amongst international stakeholders in rabies control and is now being used to encourage international policy change, attract investment and increase delivery of effective rabies control programmes in canine rabies endemic countries.

Awareness of Rabies Risk in a Sample of Travelers Attending an Irish Travel Medicine Clinic

Introduction: Many countries endemic for the rabies virus are popular tourist destinations for travelers from developed countries. This study was designed to assess the level of awareness of rabies in a sample of travelers attending a travel medicine clinic and to assess whether the rabies-specific information provided verbally should be reinforced into a written form before the travelers complete their rabies pre-exposure prophylaxis. Methods: During a 4-month period travelers intending to travel to rabies-endemic countries completed a questionnaire, and received standardized information on rabies risk reduction. When they received booster doses of rabies vaccine, subjects were asked if they considered themselves at risk of rabies and they were also asked to list the steps they would take if bitten by an animal. Results: Thirty travelers participated in this study. A significant proportion of them underestimated their personal risk. This trend persisted at follow-up despite intervening education. Many travelers did not recognize trekking as a risk factor for rabies exposure. While most travelers were aware that dogs can transmit rabies, very few understood the risk posed by other warm-blooded animals. The majority of travelers expected to be safely treated in the event of developing rabies. Most travelers understood the importance of consulting a doctor following potential rabies exposure but a minority of travelers was aware of the need for immediate first-aid treatment. Conclusion: Travelers’ knowledge of the information provided during their medical consultation appears to decay rapidly. This study points to the importance of reinforcing this advice by providing a convenient reference guide which could be inserted into the traveler’s vaccination booklet. Keywords: Rabies, Risk, Travellers

Rabies in South Asia: Fighting for Elimination

South Asia is regarded as the hot spot for the tourist and travelers. Unfortunately, three big countries (India, Pakistan and Bangladesh) of this region belong to top five rabies endemic countries of the world. Around 55,000 people die of rabies every year globally and 45% of them belong to South and South East Asia. Countries are now working on the elimination of rabies by the year 2020. Elimination of animal rabies is the pivotal of controlling human rabies. Dog (primary source) registration, population control and mass vaccination are the different ways of eliminating animal rabies. Pre (for risk groups including travelers) and post-exposure vaccine is the core for controlling human rabies. Post-exposure vaccine consists of nerve tissue vaccine and tissue culture vaccine. Due to low antigenicity and post-vaccine neurological complications all countries of South Asia except Pakistan have phased out the production and use of nerve tissue vaccine. To reduce the cost intramuscular regimen is now largely replaced by intradermal regimen and equine rabies immunoglobulin will probably replace human immunoglobulin in future for category III animal bite. 'SAARC' took initiatives for rabies elimination through 'SAARC development fund' which would hopefully play a vital role in regional collaboration to make the region rabies free.

Molecular epidemiology of rabies viruses circulating in two rabies endemic provinces of Laos, 2011-2012: regional diversity in Southeast Asia.

BackgroundAlthough rabies is endemic in Laos, genetic characterization of the viruses in this country is limited. There are growing concerns that development in the region may have increased transport of dog through Laos for regional dog meat consumption, and that this may cause spillover of the viruses from dogs brought here from other countries. This study was therefore undertaken to evaluate the current rabies situation and the genetic characteristics of rabies viruses currently circulating in Laos.MethodsWe determined the rate of rabies-positive samples by analyzing data from animal samples submitted to the Lao Ministry of Agriculture and Forestry’s National Animal Health Centre rabies laboratory from 2004 through 2011. Twenty-three rabies-positive samples were used for viral genetic characterization. Full genome sequencing was performed on two rabies viruses.ResultsRabies-positive samples increased substantially from 40.5% in 2004 to 60.2% in 2009 and continued at this level during the study period. More than 99% of the samples were from dogs, followed by cats and monkeys. Phylogenetic analyses showed that three rabies virus lineages belonging to the Southeast Asian cluster are currently circulating in Laos; these are closely related to viruses from Thailand, Cambodia and Vietnam. Lineages of the circulating Laos rabies viruses diverged from common ancestors as recently as 44.2 years and as much as 55.3 years ago, indicating periodic virus invasions.ConclusionThere is an increasing trend of rabies in Laotian animals. Similar to other rabies-endemic countries, dogs are the main viral reservoir. Three viral lineages closely related to viruses from neighboring countries are currently circulating in Laos. Data provide evidence of periodic historic exchanges of the viruses with neighboring countries, but no recent invasion.

Rabies: How can we protect travellers?

UK travellers often visit rabies-endemic countries. Lynda Bramham discusses how pre-travel advice, pre-exposure vaccines and prompt medical attention after a potential exposure can protect travellers against the disease

2015 Outbreak of Canine Rabies in Malaysia: Review, Analysis and Perspectives

Rabies is an acute fatal zoonotic encephalitis caused by a Lyssavirus belonging to the family rhabdoviridae responsible for about 69000 deaths annually. In July, 2015 Malaysia lost its rabies free status due to an outbreak of canine rabies that started from Perlis state and later moved to Kedah and Pulau Pinang states of Malaysia. This study was carried out to review available data on rabies and determine the incidence of rabies during the outbreak, the susceptible population of dogs, the number of dogs culled, the number of dogs vaccinated and lessons that can be learned from the outbreak using data principally from the OIE and other public domain sources. Statistical calculations employed chi square analysis at 95% confidence level using SPSS version 22. The incidence of rabies was 0.10% (CI= 0.05%, 0.18%). There was significant difference (P<0.0001) between the number of cases, number of susceptible dogs, number of dogs destroyed and number of dogs vaccinated between the 3 states in Malaysia with Perlis having the highest number of cases, Kedah having the highest number of susceptible dogs, Pulau Pinang having the highest number of culled dogs but with the least number of vaccinated dogs and Kedah having the highest number of vaccinated dogs. Perlis had the highest number of cases followed by Pulau Pinang. Kedah with the highest number of vaccinations recorded only 1 case of rabies. There was no case of human rabies despite numerous dog bite cases during the outbreak. The proximity of the 3 states especially Perlis to a rabies endemic country must have led to the outbreak of the infection. Mass vaccination of dogs along with short term targeted culling is important in stopping rabies outbreaks. Territories within close proximity to endemic locations must maintain more surveillance against transboundary diseases like rabies. Post exposure prophylaxis is necessary immediately after exposure to rabies to prevent human infection.

Dogs Entering the United States from Rabies-Endemic Countries, 2011-2012.

International dog imports pose a risk because of the potential movement of disease agents, including the canine rabies virus variant which has been eliminated from the United States since 2007. US regulations require a rabies vaccination certificate for dogs arriving from rabies-endemic countries, but permit the importation of dogs that have not been adequately immunized against rabies, provided that the dogs are confined under conditions that restrict their contact with humans and other animals until they have been immunized. CDC Form 75.37, 'Notice to Owners and Importers of Dogs', explains the confinement requirements and serves as a binding confinement agreement with the importer. In this evaluation, we describe the characteristics of unimmunized dogs imported into the United States over a 1-year period based upon dog confinement agreements recorded at the Centers for Disease Control and Prevention (CDC) quarantine stations. Confinement agreements were issued for nearly 2800 unimmunized dogs that entered the United States during 1 June 2011-31 May 2012, the majority of which travelled to the United States by air and without any seasonal pattern in import volume. Over 60% of these animals were puppies <3 months of age and included a wide variety of breeds. The dogs arrived from 81 countries, with the majority arriving from North America or Europe. Dogs placed on confinement agreements had final destinations in 49 states. California, New York, Texas, Washington and Florida received the largest number of dogs on confinement agreements. These results (which do not reflect human travel or US dog ownership data) suggest that a large portion of unimmunized dogs arrive from rabies-endemic countries for commercial, shelter and rescue purposes. Further evaluation and key stakeholder involvement are needed to assess whether the current dog importation regulations are an adequate compromise between the benefits and risks of dog importation.

Rabies: prevention strategies for overseas travellers.

Rabies is a fatal viral disease that causes acute inflammation of the brain in humans. Transmission is usually through a bite or scratch or contact with the saliva of an infected animal. However, it is a vaccine preventable disease. It is important that those travelling to rabies-endemic countries are aware of the risk of rabies transmission and the role of pre and post-exposure vaccination.

Development and evaluation of a new immunohistochemistry-based test for the detection of rabies virus neutralizing antibodies

Rabies claims about 55 000 human lives and many hundreds of thousands of livestock every year, worldwide. Despite a heavy disease burden, laboratory facilities to diagnose the infection remain scarce in most countries of the developing world where the disease is endemic. Rapid Fluorescent Focus Inhibition Test (RFFIT) and Fluorescent Antibody Virus Neutralization Test (FAVN) are the common tests done in the rabies diagnostic laboratories to detect and quantitate Rabies Virus Neutralizing Antibodies (RVNA). RFFIT is most often employed in confirming seroconversion following prophylactic vaccination, and to aid ante-mortem diagnosis in suspected cases of rabies. Though this remains one of the most sought-after diagnostic services in rabies laboratories, the requirements for expensive anti-rabies fluorochrome antibody conjugate and a fluorescent microscope restrict its performance to only a few reference laboratories. Cost-effective laboratory diagnostic methods employing affordable technology are a need of the hour in the rabies-endemic countries. In this study we have developed a new immunohistochemistry-based neutralization test and extensively evaluated it along with RFFIT. One hundred and 20 human serum samples collected after post-exposure vaccination were subjected to both the tests for determining RVNA titers. The results obtained with the new test correlated significantly with those of RFFIT. Further validation of the inter- and intra- assay precision, lower limit of quantification (LLOQ) and specificity was also performed. The best correlation between the 2 methods, however, was observed only when the RVNA concentrations in the samples were >20 IU/mL. Overall, the immunohistrochemistry-based neutralization test yielded satisfactory results. We suggest that it might serve as a cost-effective alternative to RFFIT in low-resource settings in the developing countries.

Cost Analysis of Post Exposure Prophylaxis of Rabies in A Tertiary Care Centre- A Cross Sectional Study

India is a rabies endemic country with the highest incidence of rabies cases with approximately 30,000 deaths per year and more than 1,000,000 people undergoing anti rabies vaccination every year. Around 30 to 60% of pre exposure prophylaxis are given to children below the age of 15.The following study was conducted in the district of Thrissur, in the state of Kerala. This study was conducted to analyze the cost of post exposure prophylaxis and to compare assumed cost of pre exposure prophylaxis. Our study included 213 patients attended anti rabies clinic for post exposure prophylaxis. Among the group 63.4% were adults and 36.6% were children. Majority were category III exposure The analysis of the direct cost of post exposure vaccination was done and compared with the cost of pre exposure prophylaxis. The post exposure vaccination included 4 doses of Intra dermal rabies vaccination -two site regime (modified Thai red cross regime) along with rabies immunoglobulin for category 3, added up to $ 4540. This was compared with the cost that would have occurred if these patients had previously received pre exposure prophylaxis which was $890. It was found that Pre exposure prophylaxis came to only to one fifth the cost of post exposure prophylaxis. We infer that Pre exposure prophylaxis is a cost effective strategy which can aid in the control and elimination of rabies in endemic countries. th

Pup Vaccination Practices in India Leave People to the Risk of Rabies — Lessons from Investigation of Rabies Deaths Due to Scratch/Bite by Pups in Remote Hilly Villages of Himachal Pradesh, India

Rabies, a zoonotic disease, kills 55,000 persons every year globally and 20,000 persons in India. Two years back, we learnt of two deaths due to Rabies in remote village Shiv Shankar Garh of Arki block of District Solan and decided to investigate the deaths. Method: A rapid response team was constituted to investigate the deaths. We interviewed the villagers & family to conduct verbal autopsy. A line list of entire population of village and household contacts of the patients, who died, were made along with the line list of dogs and cattle. Results & Discussion: A-month-old stray pup brought home by the family and had caused an abrasion with its toes on the hands of both the deceased on June 2, 2011 while playing. The lady developed paralysis of the arm on July 3, 2011 and 3 days later developed symptoms of hydrophobia. She died on July 9, 2011. Her son had developed hydrophobia 10 days after that and died on July 19, 2011. Assumption that bite or abrasion by a small pup of one month cannot be fatal proved otherwise. Lack of awareness regarding the fatality of even a scratch and lack of knowledge regarding local treatment of the wound & vaccination of both human and pups, were the main reasons for the deaths. While such incidents keep on happening, and the veterinarians in India are refusing to vaccinate pups before three months of age, as pups may not develop immunity before that age, leaving unsuspecting people to the risk of rabies. Conclusions: Humans can be exposed to rabies even by pups below 3 months of age. Recommendation: Pup vaccination schedule in rabies endemic countries like India need revision. Veterinarians and public health experts need to strongly consider vaccinating pups at first contact with humans even if they are less than 3 months of age. A booster to the pup can be given at three months of age with subsequent yearly boosters.

Tour Leaders’ Knowledge of and Attitudes toward Rabies Vaccination, Taiwan

Tour Leaders’ Knowledge of and Attitudes toward Rabies Vaccination, Taiwan

Rabies Post-Exposure Prophylaxis of Overseas Travelers in the International Travel Clinic of the National Medical Center from 2006 to 2012, Korea

BackgroundRabies is an acute fatal viral disease generally transmitted from infected animals to humans through bites. It is distributed worldwide. The number of Korean people traveling to rabies-endemic countries and being bitten by infected animals has been increasing recently. Therefore, we investigated international travelers who received rabies post-exposure prophylaxis (PEP) at the National Medical Center (NMC) and compared the data with those of other clinics.Materials and MethodsThis study was a retrospective review of 106 patients who visited the International Travel Clinic of the NMC and received rabies PEP between July 2006 and December 2012. During that period, we used the Essen intramuscular regimen protocol. Complete rabies PEP was defined as 5 doses of rabies vaccination with or without rabies immunoglobulin (RIG) administration according to the World Health Organization guidelines.ResultsA total 106 cases documented within the period of 6 years were selected, including 10 children younger than 15 years and 96 older than 15 years. The mean age of the patients who received PEP was 33.4 years. Of the patients, 53 were male and another 53 were female. Most of the exposures occurred in Southeast Asia, predominantly from dog bites (71, 66.9%). The lower extremities were the most frequent site of exposure (37, 34.9%). All the patients began receiving rabies vaccination for prophylaxis after exposure, and 51 received rabies vaccination with RIG. Meanwhile, 74 cases (69.8%) initiated rabies vaccination overseas, but only 10 of them received RIG while overseas; the remaining 32 (30.2%) initiated rabies vaccination after returning to Korea. Within 7 days, all the children and 74 adults received their first rabies vaccination. Six adults initiated first rabies vaccination after 1 week. Eleven of the 106 patients stopped PEP before 5 doses, among whom 4 (1 child and 3 adults) discontinued vaccination after confirming that the biting animal remained healthy throughout 10 days of observation. None of the patients had been previously vaccinated against rabies.ConclusionsMost of the overseas travelers who visited our clinic after being bitten by suspected rabid animals received appropriate rabies PEP. However, the interval between exposure and first rabies vaccination was often delayed. Tourists who plan to travel in rabies enzootic regions need to be aware that prompt initiation of PEP is important to reduce the risk for developing human rabies.

Antibodies to Australian bat lyssavirus in an asymptomatic bat carer

[Extract] The recent fatal case of Australian bat lyssavirus (ABLV) in an 8-year-old boy in February 2013[1] as well as infections in horses in May 2013[2] has prompted us to write about an earlier non-fatal exposure. In August 1996, soon after the discovery of ABLV,[3] a serological survey of 14 bat carers in Townsville, North Queensland, detected antibodies (rapid fluorescent focus inhibition test (RFFIT) 0.48 international units (IU)/mL) in a 40-year-old male. As a volunteer bat carer for 10 years, mainly of black flying foxes (Pteropus alecto) and little red flying foxes (Pteropus scapulatus), he had received multiple bites and scratches. He had never received rabies vaccine or rabies immunoglobulin. He did not care for other Australian wildlife and had not visited rabies endemic countries.

Travel and non-travel associated rabies post exposure treatment in New South Wales residents, Australia, 2007–2011: A cross-sectional analysis

Australian Bat Lyssavirus is endemic in Australian bats. More Australians are travelling to rabies (Lyssavirus 1) endemic countries. The nature and frequency of lyssavirus exposures and characteristics of New South Wales (NSW) residents exposed have not previously been described. Access to free rabies post-exposure treatment (PET) can only be arranged through Public Health Units in NSW. Details of people receiving PET after potential exposures to rabies or ABLV from 1 January 2007 to 31 December 2011 were extracted from an NSW Ministry of Health web-based database and analysed to better understand lyssavirus exposure epidemiology. Of 1195 people receiving PET, 415 exposures were in Australia and 780 abroad; 78.3% occurring in Southeast Asia, mainly Indonesia (47.6%) where most were on the island of Bali (95.2%). PET use increased substantially for domestic and international exposures. In Australia, most bat exposures were to members of the public (76.0%), rather than to people who work with bats professionally or as volunteers, with 54.1% due to bat rescue attempts. Injuries abroad were mainly from monkeys (49.4%) and from dogs (35.8%). Only 4.0% of international travellers were vaccinated prior to their exposure. Increasing rates of PET in travelling and non-travelling Australians emphasisethe need for more effective communication about appropriate animal avoidance and the measures required if exposed. Opportunities for increasing pre-exposure treatment amongst individuals likely to be exposed should be promoted.

Molecular epidemiology of human rabies viruses in Sri Lanka

Rabies is a lethal zoonotic disease caused by the rabies virus, which is transmitted by rabid animals to humans. Rabies is prevalent in all continents, with over 60% of human deaths occurring in Asia. Sri Lanka is a rabies-endemic country. This study shows that rabies afflicted more older individuals than children in Sri Lanka between 2008 and 2010. This novel finding indicates that older people in Sri Lanka should be more aware of the risk of rabies. Phylogenetic analyses of the rabies N and G genes showed that the Sri Lankan rabies viruses are distinct and probably originated from a single clone. The G–L noncoding region is highly diverse, and is suitable for the analysis of virus evolution within a country. A phylogenetic analysis of this region showed high diversity in the currently circulating Sri Lankan rabies viruses, which can be divided into seven clades. Some clades are unique to a specific geographic region, whereas others occur at multiple locations. This indicates that the movement of dogs, the main rabies-transmitting animal in Sri Lanka, is restricted in some areas but less limited in others. These data may help to formulate a more efficient rabies control program in Sri Lanka.

Discrepancies in data reporting for rabies, Africa.

Human rabies is an ancient disease but in modern times has primarily been associated with dog rabies–endemic countries of Asia and Africa. From an African perspective, the inevitable and tragic consequences of rabies require serious reflection of the factors that continue to drive its neglect. Established as a major disease only after multiple introductions during the colonial era, rabies continues to spread into new reservoirs and territories in Africa. However, analysis of reported data identified major discrepancies that are indicators of poor surveillance, reporting, and cooperation among national, international, and global authorities. Ultimately, the absence of reliable and sustained data compromises the priority given to the control of rabies. Appropriate actions and changes, in accordance to the One Health philosophy and including aspects such as synchronized, shared, and unified global rabies data reporting, will not only be necessary, but also should be feasible.

Rabies prevention in people who travel overseas

Increasing numbers of U.K. travellers are visiting rabies-endemic countries. This article describes how this invariably fatal disease is transmitted to humans and how it may be prevented by increased awareness, and pre and post-exposure vaccination. It aims to help practitioners identify patients at increased risk of rabies, and looks at the common myths and misconceptions travellers may have about rabies and rabies vaccination.

Fatal case of human rabies imported to Italy from India highlights the importance of adequate post-exposure prophylaxis, October 2011

In October 2011, an Indian man resident in Italy was admitted to a hospital in Mantua, Italy with symptoms of acute encephalitis. Due to a recent history of bite by a suspected rabid dog in India, where he had received incomplete post-exposure treatment, rabies was suspected. The patient died after 22 days of intensive care treatment and rabies was confirmed post mortem. This report stresses the need of appropriate post-exposure prophylaxis in rabies-endemic countries.