Rabies Patients Research Articles

Clinical features of rabies patients with abnormal sexual behaviors as the presenting manifestations: a case report and literature review

BackgroundAbnormal sexual behaviors presenting as manifestations of rabies have occasionally been reported in the literature, although little attention has been paid to these cases to date. This study aimed to analyze the clinical features of rabies cases with abnormal sexual behaviors as the presenting manifestations.Case presentationA case of 32-year-old man with frequent ejaculation as the initial symptom of rabies was first reported. Then, a literature review was conducted using databases including CNKI, SinoMed, VIP, Wanfang Data, ScienceDirect, ProQuest, OVID and PubMed. In addition to our case, 54 other rabies cases, with abnormal sexual behaviors as the presenting manifestations, have been reported since 1970. Among the 55 cases, 51 were male and three were female (unknown gender for one case), with ages ranging from 6 to 71 years. All cases were reported in developing countries, 46 in China. Dog bites were the major source of infection, and extremities were the main exposure sites. Overall, 46 (83.6%) cases had abnormal sexual behaviors as the initial symptoms. The major presenting manifestations were priapism and ejaculation in males and hypersexuality in females. All cases were clinically diagnosed based on medical history and clinical manifestations. Given no standardized post-exposure prophylaxis, all cases died with the survival time being between 1 and 15 days.ConclusionsThe rabies patients with abnormal sexual behaviors have unique clinical features. To avoid misdiagnosis, unexplained abnormal sexual behaviors should raise clinical suspicion of rabies.

Duclaux, Chamberland, Roux, Grancher, and Metchnikoff: the five musketeers of Louis Pasteur

The Institut Pasteur was created thanks to worldwide generosity with the aim to welcome and treat rabies patients, to provide a place for scientific research and to offer new teaching programs in microbiology. Louis Pasteur invited his main collaborators, who had accompanied him during his previous investigations at École Normale Supérieure, to join him in his new institute. They contributed to the principle discoveries of Pasteur, such as the fight against spontaneous generation, the identification of the ferments of putrefaction, the fight against the silk worm disease, the research on wine and beer, and the set-up of the first vaccines against avian cholera, anthrax, swine erysipelas and rabies. There were two scientists, Émile Duclaux and Charles Chamberland, and two medical doctors, Émile Roux, and Joseph Grancher. In addition, two Russian scientists were invited to join the Institute and to head a research laboratory, Élie Metchnikoff and Nikolaï Gamaleïa, the later will finally never join the institute.

Duclaux, Chamberland, Roux, Grancher, and Metchnikoff: the five musketeers of Louis Pasteur.

The Institut Pasteur was created, thanks to worldwide generosity with the aim to welcome and treat rabies patients, to provide a place for scientific research and to offer new teaching programs in microbiology. Louis Pasteur invited his main collaborators, who had accompanied him during his previous investigations at École Normale Supérieure, to join him in his new institute. They contributed to the principle discoveries of Pasteur, such as the fight against spontaneous generation, the identification of the ferments of putrefaction, the fight against the silk worm disease, the research on wine and beer, and the set-up of the first vaccines against avian cholera, anthrax, swine erysipelas, and rabies. There were two scientists, Émile Duclaux and Charles Chamberland, and two medical doctors, Émile Roux, and Joseph Grancher. In addition, two Russian scientists were invited to join the Institute and to head a research laboratory, Élie Metchnikoff and Nikolaï Gamaleïa; the later will finally never join the institute.

Rabies, rabies vaccine, and renal failure: Clinical issues.

Rabies is an important neurological infection that is prevalent in tropical countries. The rabid animals can bring rabies to humans by biting. The disease can result in serious neurological problem and death is the end result. The best way is prevention of disease by postexposure prophylaxis against rabies. The effect of rabies on the renal system is little mentioned in the literature. In the previous literature, acute kidney injury was observable in half of the rabies patients. Rabies is also transmittable by organ transplantation. Although it is rare and <10 cases had ever been reported in literature, it is proven that kidney transplant patients are at risk of getting rabies if the donor come from endemic country or with a history of travel to endemic country and has unclear cause of death. Regarding rabies immunization, the use of vaccination for patients with the underlying renal failure is interesting. In this short article, the authors summarize on those important clinical issues of rabies and renal failure.

Rabies: a medical perspective

Rabies is an acute neurological infection of humans and animals, caused by rabies virus and usually transmitted by animal bites. After an incubation period usually lasting weeks or longer, a variety of prodromal symptoms may occur. Encephalitic rabies (80% of cases) is associated with episodes of generalised arousal or hyperexcitability and hydrophobia, in which spasms involve the contraction of inspiratory muscles with swallowing. Paralytic rabies (in 20% of cases) is characterised by progressive lower motor neuron weakness. Laboratory investigations are important for confirming an ante mortem diagnosis of rabies. Cardiopulmonary and many other complications, including multiple organ failure, are common in aggressively managed rabies patients in critical care units. No effective therapy is available for rabies and survivors are uncommon. In contrast, preventative measures for rabies are highly effective after recognised exposures.

A Serological Study in Response to People at Occupational Risk of Rabies Virus Exposure in Nepal

A serological study to know the antibody titer against rabies virus in human beings, who are at occupational risk, was conducted in Nepal in 2014. A total 44 serum samples were collected out of which 21 samples were collected from medical professionals (working at Sukraraj Tropical Hospital) and 23 were collected from veterinary professionals (working at Central Veterinary Hospital, Central Veterinary Laboratory and Rabies Vaccine Production Laboratory) in Kathmandu. Among the 44 samples, 4 were collected from unvaccinated persons. The other 40 people sampled were vaccinated with inactivated rabies vaccine. All samples were subjected to the Rabies Fluorescent Focus Inhibition Test (RFFIT) test at Centre for Disease Control and Prevention, Atlanta, USA. The antibody level of 7 persons was found to be less than the WHO recommended titer of 0.5 IU/ml. Six medical professionals and one veterinary professional had a low rabies virus neutralizing antibody titer. The 4 samples collected from unvaccinated persons, and 3 collected from vaccinated persons had a titer below 0.5 IU/ml. This study shows that medical and veterinary professionals who are responsible to nurse or handle rabies patients, rabid animals or rabies virus are still at high risk. This underscores the importance of recommendations for regular serological testing of occupationally exposed individuals and vaccinating booster dose when necessary.

Study on Fate of Rabies Patients following Canine Animal Bite or Scratch

Background &amp; Objective: Rabies is major public health problem in Bangladesh, although little epidemiological information is available about the disease. The present study is, therefore, intended to assess the extent of animal bite and rabies, and the status of post-exposure prophylaxis in Bangladesh.&#x0D; Materials &amp; Methods: Data were retrospectively collected from clinical records and registers of patients with animal bites and rabies cases attended at IDH between January 2010 to December 2012. All the rabies cases were diagnosed clinically and were analysed using descriptive statistics.&#x0D; Result: Of the 276 patients of rabies patients admitted in the Infectious Disease Hospital, Mohakhali, Dhaka during the period 2009 to 2013, about 39% were 10 or &lt;10 years old and 26.4% more than 40 years old with mean age of the patients being 26 years (range: 2-90 years). Over three-quarters (76.1%) were male (3:1). Majority (80.1%) was rural resident. The injuries were primarily inflicted by bite (92%) and rarely by scratch (8%). About 96% had injury with bleeding. Dogs were the prime biting animal (88%) followed by cat (7.2%), jackal (2.9%), mongoose (1.4%) and others (0.4%). About three-quarters (74.6%) of the animals were stray animal, followed by rabid (mad) animal (18.1%), pet (4.3%) and others (2.9%). In most cases (82.6%) the biting animal could not be traced. Most of the patients received bite in lower limbs (76.4%), were multiple (70%) and were of category III (96%). Of the total cases, only 34(12.3%) received vaccine before admission at our hospital. Of them only 9(26.5%) completed the course schedule. Half of the patients received vaccine from the pharmacy and 38.3% from Institute of Public Health (IPH). However, over 60% of the patients were uncertain about their preservation status. More than 60% of patients took more than 40 days to develop rabies following bite, 27.5% 20 - 40 days and 10.9% &lt; 20 days. The mean interval was 72.8 days (range 10 days to 3 years).&#x0D; Conclusion: Rabies is usually a disease of children, male and rural resident primarily caused by bite of stray dogs. The post-exposure prophylaxis is at its worst with majority does not receive vaccine. Protection by rabies immunoglobulin is even rare. None of the patients survived of the disease.&#x0D; Ibrahim Cardiac Med J 2013; 3(1&amp;2): 32-38

Evaluation of Rapid Neutralizing Antibody Detection Test against Rabies Virus in Human Sera.

Rapid and easy determination of protective neutralization antibody (NAb) against rabies in the field is very important for an early and effective response to rabies in both animal and human health sectors. The rapid neutralizing antibody detection test (RAPINA), first developed in 2009 and then improved in 2012, is a quick test allowing detection of 0.5 IU/ml antibodies in human and animal sera or plasma. This study aimed to assess the RAPINA test by comparison with rapid focus fluorescence inhibition test (RFFIT), using 214 sera of vaccinated and unvaccinated professional dog butchers, laboratory workers and rabies patients in Vietnam. The sensitivity, specificity, false negative rate, false positive rate and concordance of the RAPINA test as compared to RFFIT were 100%, 98.34%, 0%, 1.66% and 98.6%, respectively. The positive predictive value and negative predictive value were 91.7% and 100%, respectively when RAPINA test was used. With its remarkable sensitivity, specificity and easy implementation, RAPINA test can be used for rapid determination of NAb in the field.

Success Story of a Low Cost Intra-Dermal Rabies Vaccination (IDRV) Clinic-Lessons Learnt over Five Years of 12,000 Patient Vaccinations “Without Failure” at DDU Hospital Shimla, Himachal Pradesh, India &amp;lt;br/&amp;gt;—“Saving a Drop of Rabies Vaccine and Immunoglobulins” 12 Innovations to Make Himachal Pradesh Rabies Free State by 2020

Background: Rabies is a dreaded disease and an estimated 55,000 people die of rabies every year. Himachal Pradesh is in the North bordering China and is predominantly rural and hilly. Villages are near forests, where wild reservoirs of rabies exist. Since health facilities are not accessible easily, we need to innovate on existing schedules of rabies vaccination keeping in view the compliance of the patients and affordability so as to give them the best possible option of treatment. In the year 2006 and 2007, we, at DDU Hospital Shimla, experienced a severe shortage of rabies vaccine and patients were running from pillar to post to fetch rabies vaccine. At the same time, we learnt that some of the patients died because either they were not able to purchase the vaccine, mostly because of its high cost, $35, or they ignored the animal bites and did not seek the treatment. Since last year, we have been experiencing non-availability of rabies immunoglobulins (RIGs) in the market and have to innovate new schedules and techniques to save lives of the patients. Methods: During shortage of rabies vaccine in 2008, we contemplated to start a low cost intra-dermal (ID) clinic so as to make rabies vaccine affordable as intramuscular (IM) vaccination cost five times more than ID vaccination. But, there were three main hurdles. One hurdle was the non-availability of rabies vaccine vials having written on them “For IM/ID use” and another hurdle was only fewer animal bite patients attending the DDU Hospital, sometimes only one or two per day, which was insufficient to open a vaccine vial and distribute among them. The third problem being faced was reluctance of the hospital doctors to prescribe ID vaccine as this was not the practice at higher teaching institutions, including medical colleges. We contacted a vaccine company and few vials labeled as “For IM/ID use” were sourced from Mumbai (1200 km away from here). We asked the Chief Medical Officer, Shimla district to write a letter to all health facilities around our Hospital to give first aid to animal bite patients and then refer them to DDU Hospital for vaccination. Now we were able to pool the patients and divide a single 1 ml vaccine vial among four patients. After continuous advocacy, our stress that WHO has given its approval for ID use of rabies vaccine and that subsequent approval has been granted by Government of India was enough for doctors to prescribe the vaccine as ID. Last Year, we got ethical approval to inject rabies Immunoglobulins (RIGs) only locally in and around the wound at times of scarcity of RIGs in the market. The subsequent follow up of patients proved life saving in crisis of shortage of RIGs. Due to shortage of RIGs we innovatively vaccinated people bitten by rabid dogs or people who had consumed rabid cow’s milk and followed them for outcome, apart from having Rabies Fluorescent Focus Inhibition Test (RFFIT) was done for few of the patiens for verification of protective titers. We innovated a technique of extraction of last drop of vaccine from the vial and also saved a drop of RIGs being used for test dose before giving RIGs to the patients. Results: The first low cost anti-rabies clinic was started on August 2, 2008 after long advocacy sessions with the authorities and the doctors. Since then, we have done many innovations based on local requirements and patients’ feedback and accessibility to treatment. We have given pre and post-exposure prophylaxis to more than 12,000 animal bite victims over more than five years period in this single clinic, saving lives as well as money without any failure even in difficult rabid animal bite cases. Our innovation helped us save the vaccine and immunoglobulins till the last drop. Conclusions: Innovative ways by health providers backed by extensive literature review and scientific evidence can help patients get low cost health deliverables that increase their compliance as medicines/vaccines become affordable to them. Third world countries need to innovate their own ways to solve their problems of scanty resources and find innovative solutions to conquer them, rather than looking elsewhere for solutions.

Role of the blood-brain barrier in rabies virus infection and protection.

Rabies is an acute, progressive encephalitis caused by infection with rabies virus (RABV). It is one of the most important zoonotic infections and causes more than 70,000 human deaths annually ( http://www.rabiescontrol.net ). It has long been held that a rabies infection is lethal in humans once the causative RABV reaches the central nervous system (CNS); however, this concept was challenged by the recent recovery of a small number of rabies patients. An analysis of these patients revealed that the bloodbrain barrier (BBB) played a major role in protection against the virus. The main reason for the survival of these patients was enhanced BBB permeability after infection with the causative agent (usually bat-originated RABV showing reduced pathogenicity), which allowed immune cells to enter the tissues of the CNS and clear the infection (Willoughby et al., 2005). These findings have been confirmed in animal infection experiments (Wang et al., 2005; Roy and Hooper, 2007, 2008; Faber et al., 2009). Thus, the BBB has attracted the attention of scientists interested in the pathogenesis of, and therapeutic approaches, for rabies. This paper introduces the role of the BBB in rabies infections and protection of the CNS and provides insight into future treatments for patients with clinical rabies.

Metabolomics of cerebrospinal fluid from humans treated for rabies.

Rabies is a rapidly progressive lyssavirus encephalitis that is statistically 100% fatal. There are no clinically effective antiviral drugs for rabies. An immunologically naïve teenager survived rabies in 2004 through improvised supportive care; since then, 5 additional survivors have been associated with use of the so-called Milwaukee Protocol (MP). The MP applies critical care focused on the altered metabolic and physiologic states associated with rabies. The aim of this study was to examine the metabolic profile of cerebrospinal fluid (CSF) from rabies patients during clinical progression of rabies encephalitis in survivors and nonsurvivors and to compare these samples with control CSF samples. Unsupervised clustering algorithms distinguished three stages of rabies disease and identified several metabolites that differentiated rabies survivors from those who subsequently died, in particular, metabolites related to energy metabolism and cell volume control. Moreover, for those patients who survived, the trajectory of their metabolic profile tracked toward the control profile and away from the rabies profile. NMR metabolomics of human rabies CSF provide new insights into the mechanisms of rabies pathogenesis, which may guide future therapy of this disease.

Analysis of the genetic differences in the nucleoprotein between rabies virus and its vaccine strains in Guizhou province from year 2005 to 2010

This study was to explore the differences in the nucleoprotein gene between rabies virus (RABV) and its vaccine strains in Guizhou province from year 2005 to 2010. Samples from 4 rabies patients and cerebral tissue samples of 28 rabies infected dogs were collected from different districts in Guizhou province between year 2005 and 2010. Direct Immunofluorescence Assay (DFA) and RT-nested PCR assay were applied to detect the overall length of N gene sequence. Meanwhile, based on the comparison between the homology and phylogenetic tree, the differences in N gene sequence between the prevalent RABV and the RABV vaccine strains collected from NCBI database in these years. According to DFA and RT-nested PCR assay, the antigen and nucleic acid of the 21 dogs and 4 human samples were both confirmed positive; whose full length of N gene sequences were both 1353 bp. The homological analysis showed that the 25 strains of RABV virus and the RABV type I virus stored by GenBank database shared a high homology in N gene nucleotide and amino acid sequences, which were 89%-100% and 98%-100%, respectively. Besides, the homology between the 25 strains of RABV virus and its vaccines in nucleotide and amino acid sequences were separately 86%-95% and 96%-100%. The N gene of vaccines for livestock shared the highest homology with HEP-Flury strain in the nucleotide and amino acid, which were 88%-89% and 98%-99%, respectively. The vaccines for human use showed its greatest homology with the CTN strain in nucleotide (86%-100%) and amino acid (96%-100%). The phylogenetic tree analysis indicated that the 25 strains of RABV virus, RABV type I virus and the CTN vaccine strains constituted one individual cluster, which was least different from the CTN vaccine for human use. The prevalent RABV virus, the vaccine HEP-Flury for livestock and the vaccine CTN for human use were found to be highly similar in N gene expression in Guizhou province from 2005 to 2010.

Human rabies in rural Bangladesh

Rabies is a major public health problem in Bangladesh, where most of the population live in rural areas. However, there is little epidemiological information on rabies in rural Bangladesh. This study was conducted in 30 upazilas (subdistricts) covering all six divisions of the country, to determine the levels of rabies and animal bites in Bangladesh. The total population of these upazilas was 6 992 302. A pretested questionnaire was used and data were collected by interviewing the adult members of families. We estimated that in Bangladesh, 166 590 [95% confidence interval (CI) 163 350-170 550] people per year are bitten by an animal. The annual incidence of rabies deaths in Bangladesh was estimated to be 1·40 (95% CI 1·05-1·78)/100 000 population. By extrapolating this, we estimated that 2100 (95% CI 1575-2670) people die annually from rabies in Bangladesh. More than three-quarters of rabies patients died at home. This community-based study provides new information on rabies epidemiology in Bangladesh.

Surveillance on the etiology and genetic characteristics of rabies in Hunan province, from 2008 to 2009

To analyze the etiology of rabies in Hunan province and the genetic characteristics of rabies N gene isolated from 2008 to 2009. Direct immunofluorescence assay (DFA) and nested PCR were employed to detect the monitoring samples including brain tissues of dogs and saliva, serum or urine which were collected in 2008 to 2009, from the rabies patients. Positive samples were sequenced by ABI3730 gene analyzer for the full length of the N gene target. The homology and hpylogeography of the rabies virus were analyzed after the phylogenetic tree was constructed by Blast, Clustal W and Mega 4.0 software. Of the 1451 tissue samples from the dogs' brain, 31 were positive under DFA and the positive rate was 2.14%. The DFA positive samples were redetected by RT-PCR and the positive rate was 1.17%. 56 samples of saliva, serum and urine samples were detected by RT-PCR from the rabies patients, with 3 positives and the positive rate was 5.36%. The length of nest PCR products were 255 bp. The rates of homology to the nucleotide and the amino acid of rabies N gene were 87.2% - 87.9% after compared to the pasture strain. The phylogenetic tree was successfully built and 20 strains isolated lately belonged to the rabies gene type I. The epidemic situation of human and dogs rabies in Human were relatively stable, with all the isolated rabies virus belonging to genotype I, without any variation.

Molecular Epidemiology of Rabies Virus in Vietnam (2006–2009)

This study was aimed at determining the molecular epidemiology of rabies virus (RABV) circulating in Vietnam. Intra vitam samples (saliva and cerebrospinal fluid) were collected from 31 patients who were believed to have rabies and were admitted to hospitals in northern provinces of Vietnam. Brain samples were collected from 176 sick or furious rabid dogs from all over the country. The human and canine samples were subjected to reverse transcription-polymerase chain reaction analysis. The findings showed that 23 patients tested positive for RABV. Interestingly, 5 rabies patients did not have any history of dog or cat bites, but they had an experience of butchering dogs or cats, or consuming their meat. RABV was also detected in 2 of the 100 sick dogs from slaughterhouses. Molecular epidemiological analysis of 27 RABV strains showed that these viruses could be classified into two groups. The RABVs classified into Group 1 were distributed throughout Vietnam and had sequence similarity with the strains from China, Thailand, Malaysia, and the Philippines. However, the RABVs classified into Group 2 were only found in the northern provinces of Vietnam and showed high sequence similarity with the strain from southern China. This finding suggested the recent influx of Group 2 RABVs between Vietnam and China across the border. Although the incidence of rabies due to circulating RABVs in slaughterhouses is less common than that due to dog bite, the national program for rabies control and prevention in Vietnam should include monitoring of the health of dogs meant for human consumption and vaccination for workers at dog slaughterhouses. Further, monitoring of and research on the circulating RABVs in dog markets may help to determine the cause of rabies and control the spread of rabies in slaughterhouses in Vietnam.

Clinical and epidemiological features of human rabies cases in the Philippines: a review from 1987 to 2006

Rabies viral infection causes a fatal encephalomyelitis. In humans, classic features include hydrophobia, aerophobia, hypersalivation, agitation, and neurological symptoms. In the Philippines, canine rabies contributes to a significant burden of human disease. We retrospectively reviewed the medical records of 1839 patients admitted to San Lazaro Hospital, Manila, Philippines between 1987 and 2006, with a clinical diagnosis of rabies. We used the World Health Organization case definition for clinical rabies, which is defined by the presence of hydrophobia. Male patients outnumbered females by 2.2 to 1 and twice the number of adults were affected compared with children. Most patients were indigent. Dog bites occurred more than cat bites (97.1% vs. 2.9%) and most cases were caused by a single bite (86.2%), compared to multiple bites (8.7%). Bites to the face, head, and neck led to shorter incubation times, yet the incubation period varied, with most cases (42.7%) occurring in the bracket of 91-365 days post-exposure. Clinical symptoms included hydrophobia in all cases, as per our case definition, and aerophobia in 95.5%; only 9.4% had fever, 9.2% exhibited restlessness, and 6.7% exhibited hypersalivation. Localized neurological symptoms included pain (4.1%), numbness (2.6%), and itching (2.3%). None of the patients received appropriate post-exposure prophylaxis (PEP). This study examines the largest cohort of rabies patients reported to-date. Better understanding of clinical disease manifestations may help in salvage efforts to save patients with rabies. Knowledge of epidemiological factors will improve preventative efforts to reduce suffering from rabies.

Comparative detection of rabies RNA by NASBA, real-time PCR and conventional PCR

Five methods for the RNA detection of rabies virus were directly compared in this study. These included conventional nucleic acid sequence-based amplification with electrochemiluminescence (NASBA-ECL) assay, reverse transcription (RT)-heminested (hn) polymerase chain reaction (PCR) and TaqMan real-time RT-PCR using protocols as described previously. The first two methods have been routinely utilised for ante-mortem diagnosis of human rabies in Thailand and other rabies-endemic Asian and African countries. In addition, two real-time NASBA assays based on the use of a NucliSens EasyQ analyser (NASBA-Beacon-EQ) and LightCycler real-time PCR machine (NASBA-Beacon-LC) were studied in parallel. All methods target the N gene, whereas the L gene is used for RT-hnPCR. Using serial dilutions of purified RNA from rabies-infected dog brain tissue to assess sensitivity, all five methods had comparable degrees of sensitivities of detection. However, both real-time NASBA assays had slightly lower sensitivities by 10-fold than the other three assays. This finding was also true (except for TaqMan real-time RT-PCR due to a mismatch between the target and probe sequences) when laboratory-adapted (challenge virus standard-11) virus was used in the assays. Testing on previously NASBA-ECL positive clinical samples from 10 rabies patients (saliva [6] and brain [4]) and 10 rabies-infected dog brain tissues, similar results were obtained among the five methods; real-time NASBA assays yielded false-negative results on 2 saliva samples. None of the assays showed positive results on cerebrospinal fluid specimens of 10 patients without rabies encephalitis. Due to the unavailability of the NASBA-ECL assay, the results show that TaqMan real-time RT-PCR and RT-hnPCR can be useful for ante- and post-mortem diagnosis of rabies.

A survey of hospitals managing human rabies cases in India

A survey of 23 infectious diseases (ID) hospitals/ID wards of general hospitals was done during 2008-09 to assess the facilities for and management of rabies patients. All were Government hospitals and 0.5% of total beds was earmarked for rabies cases. The hospitals were mostly run by medical colleges (47.8%) and ID hospitals (30.4%) and located outside city limits (52.2%). The patients were admitted to 'rooms (39.1%)' and 'wards (43.5%)'. The general conditions of rabies sections i.e. sanitation and linen (65%), space and toilet (52% and 56%) and bed (47.8%) require improvements. There is a need to improve staff availability, use of personal protective wears, preventive vaccination of care providers and medicinal supplies. It is recommended to encourage hospitalization of human rabies cases to ensure a 'painless and dignified death' and this must be considered as a 'human rights' issue.

Epidemiological investigations of human rabies in China.

BackgroundThe epidemic of rabies showed a rising trend in China in recent years. To identify the potential factors involved in the emergence, we investigated and analyzed the status and characteristics of human rabies between 1996 and 2008. Moreover, the status of rabies infection and vaccination in dogs, and prophylaxis of humans after rabies exposure were analyzed.MethodsHuman rabies data in China between 1996 and 2008 collected from the annual reports of Chinese Center for Disease Control and Prevention (China CDC) were analyzed. To investigate the status of dogs and postexposure prophylaxis (PEP) of humans, brain specimens of domestic dogs were collected and detected, and the demographic details, exposure status and PEP of rabies patients were obtained in 2005 and 2006 in Guangxi, Hunan and Guizhou provinces.ResultsThe results showed 19,806 human rabies cases were reported in China from 1996 to 2008, with an average of 1,524 cases each year, and the incidence almost was rising rapidly, with the peak in 2007 (3,300 cases). It was notable that nearly 50% of the total rabies cases nationwide were reported in Guangxi, Hunan and Guizhou provinces. In these three provinces, the rabies infection rate in dogs was 2.3%, and 60% investigated cities had a dog vaccination rate of below 70%; among the 315 recorded human cases, 66.3% did not receive any PEP at all, 27.6% received inadequate PEP, and only 6.0% received a full regime of PEP.ConclusionsIn recent years, rabies is reemerging and becoming a major public-health problem in China. Our analysis showed that unsuccessful control of dog rabies and inadequate PEP of patients were the main factors leading to the high incidence of human rabies in China, then there are following suggestions: (1) Strict control of free-ranging dogs and mandatory rabies vaccination should be enforced. (2)Establishing national animal rabies surveillance network is imperative. (3) PEP should be decided to initiate or withhold according to postmortem diagnosis of the biting animal. (4) The cost of PEP should be decreased or free, especially in rural areas. (5)Education of the public and health care staff should be enhanced.

Rabies trend in China (1990-2007) and post-exposure prophylaxis in the Guangdong province.

BackgroundRabies is a major public-health problem in developing countries such as China. Although the recent re-emergence of human rabies in China was noted in several epidemiological studies, little attention was paid to the reasons behind this phenomenon paralleling the findings of the previous reports. The purpose of this study is thus first to characterize the current trends of human rabies in China from 1990 to 2007, and then to define better recommendations for improving the post-exposure prophylaxis (PEP) schedules delivered to rabies patients.MethodsThe most updated epidemiological data for 22527 human rabies cases from January 1990 to July 2007, retrieved from the surveillance database of reportable diseases managed by the Ministry of Health of China, were analysed. To investigate the efficiency for the post-exposure treatment of rabies, the details of 244 rabies patients, including their anti-rabies treatment of injuries or related incidents, were ascertained in Guangdong provincial jurisdiction. The risk factors to which the patients were predisposed or the regimens given to 80 patients who received any type of PEP were analysed to identify the reasons for the PEP failures.ResultsThe results from analysis of the large number of human rabies cases showed that rabies in China was largely under control during the period 1990–1996. However, there has been a large jump in the number of reported rabies cases since 2001 up to a new peak (with an incidence rate of 0.20 per 100000 people) that was reached in 2004, and where the level has remained until present. Then, we analysed the PEP in 244 rabies cases collected in the Guangdong province in 2003 and 2004, and found that 67.2% of the patients did not seek medical services or did not receive any PEP. Further analysis of PEP for the 80 rabies patients who received any type of PEP indicated that almost all of the patients did not receive proper or timely treatment on the wounds or post-exposure vaccination or rabies immunoglobulins.ConclusionWhile the issue of under-reporting of rabies in previous years may well be a factor in the apparent upwards trend of human rabies in recent years, the analysis of PEP in the Guangdong province provides evidence that suggests that the failure to receive PEP was a major factor in the number of human cases in China. Thus, the data underline the need for greatly improved availability and timely application of high-quality anti-rabies biologicals, both vaccines and immunoglobulins, in the treatment of human bite victims. Controlling dog rabies through pet vaccination schemes may also play a huge role in reducing the rate of human exposure. Education of the public, health care staff and veterinarians will also help to change the current situation.