Assessing the burden of human rabies in India: results of a national multi-center epidemiological survey

Post-Marketing Surveillance of the World's First Novel Cocktail of Rabies Monoclonal Antibodies: TwinRab™ in Real \-World Setting

Rabies presents with a high fatality rate, which imposes a significant global public health challenge, and therefore the use of post-exposure prophylaxis (PEP) is crucial for prevention. Monoclonal antibodies (mAbs) have emerged as a promising substitute for rabies immunoglobulins (RIGs) due to their high efficacy and standardized manufacturing process. A prospective, open-label, post-marketing surveillance study (PMS) was conducted at Byramjee Jeejeebhoy Medical College (BJMC), Pune. The study included patients aged more than 2 years who had recently sustained Category III-suspected rabid animal bite exposures. These patients were administered TwinRabTM at a dosage of 40 IU/kg in and around the wound as intralesional transfer, along with the anti-rabies vaccine (ARV). Adverse events (AEs) grading was performed with reference to the Food and Drug Administration (FDA) toxicity grading. In this study, 215 subjects received the TwinRabTM mAb with a 100% completion rate. Out of 215 patients, three (1.3%) patients in the range of 18 to 65 years of age showed solicited local AEs, which were resolved after the appropriate treatment intervention, but causality assessment was non-assessable. The overall tolerability assessment showed positive ratings from doctors (91.63%) and patients (67.91%) for the mAb cocktail. The PMS demonstrated the safety of TwinRabTM in patients who experienced Category III-suspected rabid animal bites, thereby supporting its potential as an alternative option for post-exposure prophylaxis in the management of animal bites for the prevention of rabies.

Cross-correlation and time series analysis of rabies in different animal species in Nepal from 2005 to 2018

Rabies is a fatal zoonotic disease, resulting in human and livestock deaths. In Nepal, animal rabies has posed a significant challenge to public health. Because animals are the primary source of rabies in humans, a better understanding of rabies epidemiology in animals is necessary. The objectives of this study were to determine the correlation between rabies occurrences in dogs and livestock animals and to detect the trends and change points of the disease using longitudinal data. The nationwide rabies dataset from 2005 to 2018 was analyzed using cross-correlation, multiple change points, and time series methods. Autoregressive Integrated Moving Average (ARIMA) and Neural Network Autoregression (NNAR) were applied to the time series data. The results show a positive correlation between canine rabies and livestock rabies occurrences. Three significant change points were detected in the time series data, demonstrating that the occurrences were high in the initial years but stabilized before peaking to an upward trend in the final years of the study period. Nonetheless, there was no seasonality pattern in rabies occurrences. The most suitable models were ARIMA (2,1,2) and NNAR (5,1,4) (12). Based on the study findings, both locals and tourists in Nepal need to have enhanced awareness of the potential dangers posed by rabies in canines and livestock. This study offers much-needed insight into the patterns and epidemiology of animal rabies which will be helpful for policymakers in drafting rabies control plans for Nepal.

Ante-mortem and Post-mortem Diagnosis Modalities and Phylogenetic Analysis of Rabies Virus in Domestic and Wild Animals of Gujarat, India

In the present study, total of 32 ante-mortem (AM) samples (saliva = 18 and corneal smears = 14) from six animal species (cattle = 5; camel = 1; goat = 1; horse = 1; buffalo = 4; dog = 6) and 28 post-mortem (PM) samples of domestic (cattle = 6; camel = 1; goat = 1; buffalo = 5; dog = 7) and wild animals (lion = 4, mongoose = 2; bear = 1; leopard = 1) were examined for rabies diagnosis in Gujarat, India. Direct fluorescent antibody test (dFAT) and reverse transcriptase polymerase chain reaction (RT-PCR) were applied on AM samples, whereas along with dFAT and RT-PCR, histopathological examination, immunohistochemistry (IHC) and real time PCR (qPCR) were used for PM diagnosis. Nucleotide sequencing of full nucleoprotein (N) and glycoprotein (G) genes were carried out upon representative amplicons. In AM examination, 7/18 saliva and 5/14 corneal impressions samples were found positive in dFAT and 8/18 saliva samples were found positive in RT-PCR. In PM examination, 14/28 samples showed positive results in dFAT and IHC with unusual large fluorescent foci in two samples. In histopathology, 11/28 samples showed appreciable lesion and Negri bodies were visible in 6 samples, only. Out of 23 brain samples examined. 12 samples were found positive in N gene RT-PCR and qPCR, and 10 samples in G gene RT-PCR. Phylogenetic analysis of N gene revealed that test isolates (except sample ID: lion-1; lion, Gir) form a close group with sequence ID, KM099393.1 (Mongoose, Hyderabad) and KF660246.1 (Water Buffalo, Hyderabad) which was far from some south Indian and Sri Lankan isolates but similar to Indian isolates from rest of India and neighboring countries. In G gene analysis, the test isolates form a close group with sequence ID, KP019943.1.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12088-023-01126-0.

Community attitudes and perceptions towards free-roaming dogs in Goa, India

Free-roaming dogs (FRD) represent a large proportion of the canine population in India and are often implicated as a source of conflict with humans. However, objective data on the attitudes and perceptions of local communities toward FRD are lacking. This study collected baseline data from 1141 households in Goa, India, on FRD feeding practices and assessed people's attitudes toward FRD in urban and rural communities. Additionally, respondents identified problems caused by FRD and proposed potential solutions.The study reported that 37% of respondents fed FRD with dog owners and Hindus being the most likely to feed. The majority of respondents agreed FRD were a menace (57%), a nuisance (58%) and scary (60%). Most respondents also agreed FRD were a vulnerable population (59%), that belong in communities (66%) and have a right to live on the streets (53%). Barking was the most commonly reported problem associated with FRD and the preferred solution was to impound FRD in shelters. This study reveals the complex and often misunderstood relationship between local communities and FRD and highlights potential strategies to reduce human-dog conflict.

Analysis of human rabies deaths reported at two hospitals in Karachi, Pakistan: a call to save lives by reforming rabies prevention facilities

BACKGROUND

Rabies is endemic in low- and middle-income countries. It is caused mainly by the bite of a rabid dog and is fatal if not treated effectively and in a timely manner with quality post-exposure prophylaxis. Despite a profusion of private and public healthcare centres in Sindh province, most are ill-equipped to treat dog bites.

METHODS

We analysed 129 human deaths from rabies who presented at the emergency departments of two tertiary care hospitals in Karachi over 10 y. Demographic data, time, location of the bite and distance travelled to report symptoms of rabies were recorded.

RESULTS

Most victims were male, and children were more often affected; almost none had received post-exposure prophylaxis. A total of 12% of bites were on the face, head or neck. The mean incubation period was 56 d. Most (60%) of the rabies victims travelled long distances, hoping to receive treatment.

CONCLUSIONS

Rabies deaths were either due to a lack of awareness or the non-availability of rabies immunobiologicals within easy reach. Public health services must raise awareness, conduct surveillance and provide appropriately spaced centres for free treatment of dog bites. This lethal disease must be prevented at all costs.

Active safety surveillance of rabies monoclonal antibody and rabies vaccine in patients with category III potential rabies exposure

Background

A vero cell-based inactivated Rabies Vaccine (Rabivax-S) and Rabies Human Monoclonal Antibody (Rabishield) have been approved since 2016. A post-marketing surveillance was conducted in India from 2020 to 2021 to gather real world safety data on Rabivax-S and Rabishield.

Methods

This was non-interventional active surveillance in patients with category III potential rabies exposure who were administered a post-exposure prophylaxis (PEP) regimen (Rabishield and Rabivax-S) by their healthcare providers (HCPs) as per the dosages and regimens mentioned in the package insert approved by the Indian regulators. The approved schedule for PEP was local infiltration of Rabishield on Day 0 and five doses of Rabivax-S on Day 0, 3, 7, 14, and 28 (Intramuscular route, IM) or four doses of Rabivax-S on Day 0, 3, 7, and 28 (Intradermal route, ID). The primary objective of this surveillance was to generate real-world evidence on the safety and tolerability of Rabishield and Rabivax-S. All patients enrolled in the surveillance were required to report any adverse events (AEs) occurring up to Day 31 after initiation of PEP (administration of Rabishield and the first dose of Rabivax-S) to their HCP.

Findings

A total of 1000 patients with category III potential rabies exposure were enrolled across India. 991 patients received the PEP regimen with IM Rabivax-S while 9 received a PEP regimen with the ID regimen. While 32% of the patients were <12 years of age, 11.8% were ≥12 to <18 years of age and 56.2% were ≥18 years of age. The entire PEP regimen was completed by 97.3% of the enrolled patients. A total of 69 AEs were reported in 64 patients. Out of these, 49 AEs in 47 patients were assessed as causally related to the study products (26 with Rabishield and 23 with Rabivax-S). The majority of the AEs were mild and all recovered without any sequelae. One serious adverse event (SAE) of fracture of the hand was reported which was not related to either Rabishield or Rabivax-S. No case of rabies was reported.

Interpretation

Rabishield and Rabivax-S have an excellent safety profile and are well tolerated. No participant developed rabies during 31 day follow up.

Funding

The PMS was funded by Serum institute of India Private Limited which is the manufacturer of the study products.

Progress towards dog-mediated rabies elimination in PR China: a scoping review

BACKGROUND

Rabies continues to be a serious threat to global public health endangering people's health and public health safety. In the People's Republic of China, multi-sectoral and comprehensive prevention and control strategies have aimed to extensively curb human rabies transmission. Here, we examine the current state of rabies infection in China, explore strategic interventions put in place in response to WHO's ambition of "Zero rabies deaths by 2030" and critically assess the constraints and feasibility of dog-mediated rabies elimination in China.

METHODS

This study analyzed and evaluated the process towards dog-mediated rabies elimination in China from five perspectives: namely, human, dog, policy, challenge, and prospects. Evidence-based data on progress of dog-mediated rabies elimination in China was derived from a number of sources; a literature search was undertaken using PubMed, Web of Science and CNKI databases, distribution data for human rabies cases as derived from the Data-center of the China Public Health Science and policy and document data were obtained from official websites of the relevant China ministries and commissions.

RESULTS

The incidence of human rabies cases in China have shown a downward trend year-on-year since 2007. Implementation of a government-led, multi-sectoral "One Health" approach to combating rabies has driven down the total number of rabies deaths nationwide to around 200 in 2020. The number of provincial-level administrative divisions (PLADs) reporting human cases of rabies has also decreased to 21 in 2020, 13 of which reported less than 10 cases. Furthermore, the number of outpatient visits seeking rabies post-exposure prophylaxis has risen dramatically over the past two decades, with demand being 15 times higher than it was initially. There remain however, significant gaps in rabies elimination outcomes across the different regions of China. To date the target of achieving a canine rabies vaccination rate of > 75% has not been met. The challenges of rabies immunization of dogs and dog management in underdeveloped cities and rural areas need to be addressed together with more effective animal surveillance and rabies risk from and too wildlife and livestock.

CONCLUSIONS

The Chinese government-led, multi-sectoral "One Health" approach to combating rabies and has made significant progress over the past decade. Development and adoption of more cost-effective One Health strategies can achieve more nationally beneficial rabies elimination outcomes. The ambitious target of "Zero rabies deaths by 2030" can be met through establishment of long-lasting herd immunity in dogs by means of dog mass vaccination campaigns, dog population management, epidemiological surveillance and the application of large-scale oral rabies vaccine to eliminate rabies in wild animals coupled with deployment of cost-effective human post-exposure prophylaxis, and community education.

Developments in Rabies Vaccines: The Path Traversed from Pasteur to the Modern Era of Immunization

Rabies is a disease of antiquity and has a history spanning millennia ever since the first interactions between humans and dogs. The alarming fatalities caused by this disease have triggered rabies prevention strategies since the first century BC. There have been numerous attempts over the past 100 years to develop rabies vaccineswith the goal of preventing rabies in both humans and animals. Thepre-Pasteurian vaccinologists, paved the way for the actual history of rabies vaccines with the development of first generation vaccines. Further improvements for less reactive and more immunogenic vaccines have led to the expansion of embryo vaccines, tissue culture vaccines, cell culture vaccines, modified live vaccines, inactivated vaccines, and adjuvanted vaccines. The adventof recombinant technology and reverse genetics have given insight into the rabies viral genome and facilitated genome manipulations, which in turn led to the emergence of next-generation rabies vaccines, such as recombinant vaccines, viral vector vaccines, genetically modified vaccines, and nucleic acid vaccines. These vaccines were very helpful in overcoming the drawbacks of conventional rabies vaccines with increased immunogenicity and clinical efficacies. The path traversed in the development of rabies vaccines from Pasteur to the modern era vaccines, though, faced numerous challenges;these pioneering works have formed the cornerstone for the generation of thecurrent successful vaccines to prevent rabies. In the future, advancements in the scientific technologies and research focus will definitely lay the path for much more sophisticated vaccine candidates for rabies elimination.

Is Pre-Exposure Prophylaxis a Cost-Effective Intervention to Avert Rabies Deaths among School-Aged Children in India? Comment on Royal et al. A Cost-Effectiveness Analysis of Pre-Exposure Prophylaxis to Avert Rabies Deaths in School-Aged Children in India. Vaccines 2023, 11, 88

I read with interest the article “A Cost-Effectiveness Analysis of Pre-Exposure Prophylaxis to Avert Rabies Deaths in School-Aged Children in India” by Royal et al., recently published in Vaccines [...]

Multisectoral prioritization of zoonotic diseases in Haryana (India) using one health approach

Zoonotic diseases have huge livestock and public health burden worldwide, including India. Prioritizing zoonotic diseases is one of the important tasks under 'One Health' as it facilitates effective policy making, proper allocation of resources and promotion of multisectoral collaboration. Although some efforts have been made to prioritizing zoonotic diseases at national level in India, it is important to identify priority diseases in regional settings due to wide variation in climate and demography of different states. Therefore, the present study aims to prioritize zoonotic diseases for the state of Haryana (India). One Health Zoonotic Disease Prioritization (OHZDP) tool was used in this study to prioritize zoonotic diseases. Based on literature review of the past 23 years (2000-2022) on prevalence, morbidity, and mortality of zoonotic diseases, twenty-three high-scoring zoonotic diseases in Haryana and neighboring states of India were initially shortlisted for prioritization. A three-day participatory workshop was conducted involving 17 experts representing the Health, Animal Husbandry and Wildlife departments of Haryana. The Analytical Hierarchy Process (AHP) was used to rank the criteria, which were used to score the selected diseases using the decision tree analysis. The participants selected the following 7 criteria along with their relative weights to score the diseases: (1) Severity of disease in humans, (2) Severity of disease in animals, (3) Presence of disease in the region, (4) Transmission and outbreak potential, (5) Socio-economic impact, (6) Availability of interventions, and (7) Existing inter-sectoral collaboration for surveillance and reporting. The top scoring eight diseases selected as priority zoonotic diseases for Haryana were rabies, Japanese encephalitis, bovine tuberculosis, leptospirosis, avian influenza (H5N1), brucellosis, glanders and Influenza A (H1N1). Sensitivity analysis did not reveal any significant variation in prioritization results by varying criteria weights. This is the first systemic attempt to prioritize zoonotic diseases in the state and this will help in formulating effective monitoring, prevention, and control strategies for zoonotic diseases in the regional settings.

Zona pellucida glycoproteins: Relevance in fertility and development of contraceptive vaccines

Mammalian zona pellucida (ZP) is composed of three to four glycoproteins, which plays an important role during fertilization. Mutations in the genes encoding zona proteins are reported in women with empty follicle syndrome, degenerated oocytes and those with an abnormal or no ZP further emphasizing their relevance during fertility. Immunization with either native or recombinant ZP glycoproteins/proteins leads to curtailment of fertility in various animal species. Observed infertility is frequently associated with ovarian pathology characterized by follicular atresia and degenerative changes in ZP, which may be due to oophoritogenic T cell epitope(s) within ZP glycoproteins. To avoid ovarian dystrophy, B cell epitopes of ZP glycoproteins have been mapped by using bio-effective monoclonal antibodies. Immunization with the immunogens encompassing the mapped B cell epitopes by and large led to amelioration of follicular atresia. However, their use for human application will require more rigorous research to establish their safety and reversibility of the contraceptive effect. Nonetheless, to minimize human-animal conflicts, ZP-based contraceptive vaccines have been used successfully in the population management of free-ranging animal species such as feral horses, white-tailed deer and elephants. To control zoonotic diseases, attempts are also underway to control the population of other animal species including stray dogs, which acts as one of the major vectors for the rabies virus.

Rabies virus uniquely reprograms the transcriptome of human monocyte-derived macrophages

Macrophages are amongst the first immune cells that encounter rabies virus (RABV) at virus entry sites. Activation of macrophages is essential for the onset of a potent immune response, but insights into the effects of RABV on macrophage activation are scarce. In this study we performed high-throughput sequencing on RNA extracted from macrophages that were exposed to RABV for 48 hours, and compared their transcriptional profiles to that of non-polarized macrophages (M0), and macrophages polarized towards the canonical M1, M2a and M2c phenotypes. Our analysis revealed that RABV-stimulated macrophages show high expression of several M1, M2a and M2c signature genes. Apart from their partial resemblance to these phenotypes, unbiased clustering analysis revealed that RABV induces a unique and distinct polarization program. Closer examination revealed that RABV induced multiple pathways related to the interferon- and antiviral response, which were not induced under other classical polarization strategies. Surprisingly, our data show that RABV induces an activated rather than a fully suppressed macrophage phenotype, triggering virus-induced activation and polarization. This includes multiple genes with known antiviral (e.g. APOBEC3A, IFIT/OAS/TRIM genes), which may play a role in anti-RABV immunity.

Global burden of rabies in 204 countries and territories, from 1990 to 2019: results from the Global Burden of Disease Study 2019

OBJECTIVES

Rabies is an acute lethal infectious disease caused by a lyssavirus infection. In 2018, the World Health Organization proposed a global strategic plan to end human rabies deaths by 2030. However, systematic studies on the global rabies disease burden and epidemiological trends are scarce.

METHODS

We extracted the disease burden and epidemiological data of rabies worldwide in the preceding 30 years from the Global Burden of Disease Study 2019 and performed a comprehensive analysis.

RESULTS

In 2019, the incident cases of rabies worldwide were 14,075.51 (95% uncertainty interval: 6124.33-21,618.11), and the number of deaths was 13,743.44 (95% uncertainty interval: 6019.13-17,938.53), both of which were lower than that in 1990. With the improvement of the sociodemographic index, the incident cases, the number of deaths, age-standardized incidence rate, age-standardized incidence death rate, and disability-adjusted life years of rabies all showed downward trends. Adolescents and adults aged <50 years represented the majority of rabies cases worldwide.

CONCLUSION

The global disease burden of rabies has declined over the past 30 years. Furthermore, the disease burden of rabies was closely related to the sociodemographic index level.

A Cost-Effectiveness Analysis of Pre-Exposure Prophylaxis to Avert Rabies Deaths in School-Aged Children in India

Children contribute to one-half of the total painful rabies mortalities in India. The state-of-the-art rabies mortality averting strategies need exploration for the effective implementation of pre-exposure prophylaxis (PrEP) in India. This study reports on the economic evaluation of various PrEP and post-exposure prophylaxis (PEP) strategies to avert rabies mortalities in school-aged children in India. A decision tree model has been developed for children in the age group of 5-15 years to evaluate various PrEP + PEP and PEP only regimens. The 2-site intradermal regimen administered on day zero and seven was chosen as the intervention [PrEP (I)]. ICER was calculated from the quasi-societal and quasi-health systems' perspectives for the base case analysis, along with one-way sensitivity, and scenario analyses for each regimen. The incremental DALYs averted per million population with the implementation of PrEP (I) ranged between 451 and 85,069 in 2020. The ICER was reported in the range of USD 384-352/DALY averted (non-dominant) in comparison to PEP regimens from a quasi-societal perspective. PrEP (I) is reported to be 'very cost effective' in comparison with PEP regimens from the quasi-societal and quasi-health systems' perspectives and reduce deaths by up to 89.9%. This study concludes that the PrEP (I) regimen is a cost-effective and life-saving strategy to avert painful mortalities due to rabies in school-aged children in India.

Perception of canine rabies among pupils under 15 years in Kwara State, North Central Nigeria

Rabies is an endemic, highly fatal, and vaccine-preventable disease with severe socio-economic implications. Most (99%) human rabies cases are transmitted through dog bites. Children under 15 years account for 40% of all dog bite victims and 35–50% of all rabies deaths. Rabies awareness among this vulnerable group is critical to rabies prevention. However, there is a paucity of data on rabies awareness among pupils under 15. Hence, this study assessed the awareness and attitude of pupils under 15 years towards canine rabies in Kwara state in Nigeria. The study was conducted as a cross-sectional survey of 1,388 pupils across the state using a structured questionnaire that was administered as a one-on-one interview using the Open Data Kit on Android phones in December 2019. Of the 1388 pupils included in this study, only 21.7% (n = 301) of them were aware of rabies. The mean rabies score was 1.7±0.8 and only 29.2% (n = 88/301) of the pupils had adequate knowledge of canine rabies. The dog ownership rate was 18.7% (n = 259) with an average of 1.93 dogs per household. Approximately 5% (n = 66) of the pupils have been previously bitten by a dog. One-third of the dog bite victims (35%, n = 23/66) were managed and treated at home and only 12% (n = 8/66) were treated in a health facility. The result of the multivariable logistic regression showed that students aged between 13–15 years were more likely (OR: 1.93; 95% CI: 0.72–3.01; p < 0.001) to have adequate knowledge of rabies than the younger pupils. Similarly, pupils that have dogs in their households (OR: 2.09; 95%CI: 1.49–2.75; p < 0.001) and those that reside in Kwara South (OR:1.78 95% CI:1.29, 2.44; p < 0.001) were more likely to be aware and have adequate knowledge of canine rabies respectively. Finally, Pupils from non-dog-owning households were more likely (OR:2.2; 95% CI: 1.45, 4.42; p < 0.001) to have been bitten by dogs than those from dog-owning households. The awareness and attitude of pupils under 15 to canine rabies was poor. We advocate the introduction of rabies lessons into the school curriculum in Kwara State to reduce the incidence of dog bites and prevent dog-mediated human rabies.

Rabies is an endemic disease that kills approximately 59000 persons mostly in low- and middle-income countries. The disease is mostly transmitted through dog bites and children under 15 years account for 40% of all dog bite incidents and 35–50% of all rabies death. This study assessed the knowledge and perception of canine rabies among pupils under 15 years in Kwara State, Nigeria. Our findings showed a very low rabies awareness rate (21.7%) and equally low knowledge of rabies (29.2%) with a mean knowledge score of 1.7±0.8. The dog ownership rate was 18.7% with an average of 1.93 dogs per household. Approximately 5% of the pupils have been previously bitten by a dog. One-third of the dog bite victims were managed and treated at home and only 12% were treated in a health facility. The age of the pupil, their dog ownership status and their geopolitical location within Kwara State influenced the pupil’s knowledge of canine rabies. To control rabies, we must institute multi-sectoral collaborations of critical stakeholders and introduce rabies lessons into the school curriculum in Kwara State.

Clinical, epidemiological, and spatial features of human rabies cases in Metro Manila, the Philippines from 2006 to 2015

Rabies remains a public health problem in the Philippines despite the widespread provision of rabies vaccines and rabies immunoglobulin (RIG) as post-exposure prophylaxis (PEP). Detailed descriptions of recent human rabies cases in the Philippines are scarce. This study aimed to describe the clinical, epidemiological, and spatial features of human rabies cases between January 1, 2006, and December 31, 2015. We conducted a retrospective hospital-based case record review of all patients admitted to one referral hospital in Manila who received a clinical diagnosis of rabies. During the 10-year study period there were 575 patients (average 57.5 cases per year, range 57 to 119) with a final diagnosis of rabies. Most patients were male (n = 404, 70.3%) and aged ≥ 20 years (n = 433, 75.3%). Patients mostly came from the National Capital Region (n = 160, 28.0%) and the adjacent Regions III (n = 197, 34.4%) and IV-A (n = 168, 29.4%). Case mapping and heatmaps showed that human rabies cases were continuously observed in similar areas throughout the study period. Most patients had hydrophobia (n = 444, 95.5%) and/or aerophobia (n = 432, 93.3%). The leading causative animals were dogs (n = 421, 96.3%) and cats (n = 16, 3.7%). Among 437 patients with animal exposure history, only 42 (9.6%) had been administered at least one rabies vaccine. Two patients (0.5%), young children bitten on their face, had received and a full course of rabies vaccine. Human rabies patients were continuously admitted to the hospital, with no notable decline over the study period. The geographical area in which human rabies cases commonly occurred also did not change. Few patients received PEP and there were two suspected cases of PEP failure. The retrospective design of this study was a limitation; thus, prospective studies are required.

Rabies remains a public health problem in the Philippines despite improvements in the availability of rabies vaccines and rabies immunoglobulin (RIG) as post-exposure prophylaxis (PEP). The incidence of rabies is highest in Metro Manila and surrounding areas. We reviewed the records of all human rabies patients admitted to the national infectious disease hospital in Manila between 2006 and 2015. This hospital treats most cases in this area. During the 10-year study period, human rabies cases were continuously admitted to the hospital, with no notable decline in numbers by year. Most patients were adult men bitten by domestic dogs. The geographical areas in which cases commonly occurred during the 10-year period also did not change over time. Only 9.6% of patients had received at least one dose of a rabies vaccine as PEP. Although the risk of PEP failure is reported to be almost zero, we identified two suspected cases of PEP failure. The retrospective design of this study was a limitation, and the exact details of PEP were not reliably available. As human rabies death is a significant public health concern, the circumstances of each case should be prospectively investigated. Further research is required to understand how to reduce the number of rabies cases.

Where Rabies Is Not a Disease. Bridging Healthworlds to Improve Mutual Understanding and Prevention of Rabies

Deeply embedded in local social, cultural, and religious settings, traditional healing is part of dog bite and rabies management in many rabies endemic countries. Faith healing, which usually encompasses a more holistic approach to health including physical, mental and social dimensions, is rare in the context of rabies. In Gujarat, Western India, the Hindu goddess Hadkai Mata is worshiped by low-caste communities as the Mother of Rabies in the event of a dog bite to a person or their livestock. This belief might influence people's attitudes and behaviors toward rabies prevention but has never been investigated. Through 31 in-depth interviews with healers and staff of Hadkai Mata temples, this paper explores the system of knowledge around dog and human rabies that is built and shared in these places of worship and healing. Qualitative and quantitative data were analyzed looking for convergences and divergences with the recently launched National Action Plan for dog-mediated Rabies Elimination. Results suggest that while the etiology of human rabies as a social illness is usually explained as the goddess's wish to correct misbehaving people and restore positive interpersonal relations, there is some appreciation for the biological processes of infection that lead to rabies as a physical disease. Hadkai Mata is believed to cure rabies if her patients undergo the necessary process of moral growth. Although conventional post-exposure prophylaxis is not opposed per se, it is often delayed by patients who seek traditional treatment first. Some reluctance was expressed toward mass dog vaccination because it is seen as an interference in how the goddess controls dogs, by enraging them-hence infecting them with rabies-and sending them to bite wrongdoers. Addressing these cultural perceptions is likely to be critical in achieving effective control of dog rabies in this region. The study highlights the value of multidisciplinary approaches in the control and elimination of rabies, as well as other zoonoses. This includes the importance of understanding different culturally- and religiously- mediated ways in which humans relate to animals; and looking for points of convergence and mutual understanding, upon which context-tailored, linguistically-accurate, locally acceptable, feasible and effective strategies can be designed.

Contraceptive efficacy of recombinant porcine zona proteins and fusion protein encompassing canine ZP3 fragment and GnRH in female beagle dogs

PROBLEM

To manage population of dogs (Canis familiaris), the efficacy of recombinant proteins-based contraceptive vaccines to inhibit fertility has been evaluated in female beagle dogs.

METHOD OF STUDY

Female beagle dogs (n = 4) were immunized with physical mixture of Escherichia coli-expressed recombinant porcine ZP3 with promiscuous T cell epitope of tetanus toxoid (TT-KK-pZP3) and porcine ZP4 with promiscuous T cell epitope of bovine RNase (bRNase-KK-pZP4), or with a fusion protein encompassing dog ZP3 fragment and two copies of GnRH with appropriate promiscuous T cell epitopes (dZP3-GnRH₂ ); control animals received only alum, the adjuvant. The immunized animals were followed-up for antibody titres by ELISA as well as for fertility status subsequent to mating with male dogs.

RESULTS

Active immunization of female dogs following a three injections schedule at 4-week intervals with a physical mixture of TT-KK-pZP3 + bRNase-KK-pZP4 as well as dZP3-GnRH₂ , led to generation of significant antibody titres against respective recombinant proteins. Active immunization with dZP3-GnRH₂ also led to generation of antibodies reactive with both dZP3 and GnRH. A booster dose on day 383 led to an increase in antibody titres and circulating antibodies against respective recombinant proteins could be observed on day 528. Antibodies in immune serum samples from dogs immunized with TT-KK-pZP3 + bRNase-KK-pZP4 or dZP3-GnRH₂ reacted with native canine ZP as assessed by an indirect immunofluorescence assay. Mating studies revealed a reduced number of pregnancies as well as a significant reduction in the number of pups born in the female dogs immunized with dZP3-GnRH₂ as compared to the adjuvanted control. Curtailment of pregnancy in dZP3-GnRH₂ immunized group was associated with antibody titres against dZP3-GnRH₂ . However, immunization with recombinant TT-KK-pZP3 + bRNase-KK-pZP4 did not significantly decrease the number of pups born as compared to the adjuvanted control.

CONCLUSION

These studies revealed the potential of recombinant dZP3-GnRH₂ -based contraceptive vaccine to curtail fertility in female dogs. Large scale studies to establish the efficacy and safety of this recombinant protein for the management of community dog population are thus warranted.

A Global Review of Causes of Morbidity and Mortality in Free-Living Vultures

Vulture species worldwide play a key role in ecosystems as obligate scavengers, and several populations have had precipitous declines. Research on vulture health is critical to conservation efforts including free-living vultures and captive breeding programs, but is limited to date. In this systematic review, we determined the reported causes of free-living vulture species morbidity and mortality worldwide. The most commonly reported cause of mortality was from toxins (60%), especially lead and pesticides, followed by traumatic injury (49%), including collisions with urban infrastructure and gunshot. Neglected areas of research in free-living vulture health include infectious diseases (16%), endocrine and nutritional disorders (6%), and neoplasia (< 1%). Almost half of the studies included in the review were conducted in either Spain or the USA, with a paucity of studies conducted in South America and sub-Saharan Africa. The highest number of studies was on Griffon (Gyps fulvus) (24%) and Egyptian vultures (Neophron percnopterus) (19%), while half of all vulture species had five or fewer studies. Future investigations on free-living vulture health should focus on neglected areas of research, such as infectious diseases, and areas with gaps in the current literature, such as South America, sub-Saharan Africa, and under-studied vulture species.

A Comparative Evaluation of the Estimation of Rabies Virus Antibodies among Free-Roaming, Vaccinated Dogs in Bengaluru, India

Vaccination is the practical solution for the prevention of rabies in dogs. Assessment of the immunogenicity of vaccination includes estimation of specific rabies virus neutralizing antibodies (VNA) in the target species. We undertook a study to estimate the levels of VNA in free-roaming dogs with a history of rabies vaccination in Bengaluru city, India. We compared the rapid fluorescent focus inhibition test (RFFIT) and an in-house quantitative indirect ELISA (iELISA). The study area comprised the jurisdiction of Bruhat Bengaluru Mahanagara Palike (BBMP), the Bengaluru civic body. The BBMP, along with several non-government organizations (NGO), were conducting a trap- neuter- vaccinate- release program for the prevention of dog rabies. Serum samples were collected from 250 free-roaming dogs from representative regions of BBMP, of which 125 had a VNA titre of 0.5 IU or more by the RFFIT. Furthermore, 126 dogs showed percent positivity values (PP values) more than the cut off PP value of 57.1 by the iELISA, accounting for 50.4% of satisfactory post-vaccinal serum conversion. The sensitivity and specificity of the iELISA was 94.4% and 95.2%, respectively. Based on these data, a quantitative iELISA may be a complementary tool for sero-monitoring immune responses of free-ranging animals after rabies vaccination.

Occupation-Related Biological Health Hazards and Infection Control Practices among Indian Veterinarians

Veterinarians experience different types of health hazards from their occupation. Studies on the prevalence and occurrence of biological health hazards in veterinary medicine in India are scant and probably underreported. Thus, we sought to assess the biological health hazards and infection control practices (ICPs) among veterinarians from the states of Gujarat and Maharashtra, India. A cross-sectional survey was conducted among veterinarians (n = 562) from Gujarat and Maharashtra states in India to identify biological health hazards and ICPs for the prevention of occupational health hazards during 2016–2017 by personally contacting them. Responses regarding a biological hazard and ICPs were recorded. Descriptive analysis was attempted, and continuous variables are presented as the mean ± SD. Categorical variables are reported as counts and percentages (%). Most of the veterinarians (49.3%) worked in the field and were continuously exposed to different types of biological health hazards, especially zoonoses, ranging from mild and self-limiting to fatal diseases (e.g., brucellosis (subclinical and clinical form) and rabies (fatal)) without common prophylactic vaccinations, such as rabies and tetanus. While inquiring medical health status of the veterinarians, only 35.8% of the total respondents underwent a routine medical health checkup within the past year, and 56.9% did not receive a routine dose of an anthelmintic for deworming. Forty-nine percent of the respondents took all necessary precautions, including wearing an apron, facemask, and gloves. In contrast, 10.2% of the respondents wore only an apron, and 8.4% of respondents did not take any precautions while performing their day-to-day work. In total, 40.2% of the respondents followed the proper method of handwashing, that is, washing hands between patient examinations. In contrast, 27.9% of the respondents washed their hands once after completing the work. The majority of the respondents (87.7%) reported an urgent need for occupational hazards and safety (OHS) training in continued veterinary education (CVE) programs. The present study demonstrates that veterinarians in the states of Gujarat and Maharashtra in India pay less attention to their own health that may increase the risk of occupation-related biological health hazards. These results suggest that safety and ICPs are not prioritized, which are serious concerns. These findings may be useful for developing policies to prevent occupationally related biological health hazards among veterinarians in India.

A Review and Analysis of the National Dog Population Management Program in Chile

Free-roaming dogs are a worldwide problem, with Chile having some of the highest human-to-dog ratios in the world. In 2017, Law 21.020 was promulgated and the federal government developed a national responsible pet ownership program. The objectives of this article are to describe and discuss the dog-related components of the program, to design a tool for determining human-to-dog ratios in Chile, and to make recommendations to managers to improve the program outcomes. The overarching goal of the program was to mitigate the conflict between humans and dogs, but many of the interventions were animal-focused and the indicators did not consider the perception of the Chilean public. Using human density data and known dog populations, we found that as the human density increased, there were fewer dogs per person. Veterinary services and sterilizations were the mainstay of the program and were offered for free to citizens. Education was offered to all ages through public events, as well as municipality and organization activities. The identification of dogs was obligatory for dog owners. Enforcement was not included in the program. The recommendations are to conduct preintervention baseline data collections and to tailor interventions and indicators appropriately; to use dog population size estimates determined at the local level rather than a country-wide estimate; to replace free veterinary services with low-cost sterilization campaigns; to create sustainable plans for education; and to create enforcement teams in communities.

Free-roaming dog population dynamics in Ranchi, India

Rabies causes approximately 20,000 human deaths in India each year. Nearly all of these occur following dog bites. Large-scale, high-coverage dog rabies vaccination campaigns are the cornerstone of rabies elimination strategies in both human and dog populations, although this is particularly challenging to achieve in India as a large proportion of the dog population are free-roaming and unowned. Further, little is known about free-roaming dog ecology in India which makes defining optimum vaccination strategies difficult. In this study, data collected using a mobile phone application during three annual mass vaccination and neutering (surgical sterilisation of both males and females) campaigns of free-roaming dogs in Ranchi, India (during which a total of 43,847 vaccinations, 26,213 neuter surgeries and 28,172 re-sight observations were made) were interrogated, using two novel approaches to estimate the proportion of neutered dogs that were lost from the city (assumed due to mortality or migration) between campaign years. Analysis revealed high losses of neutered dogs each year, ranging from 25.3% (28.2-22.8) to 55.8% (57.0-54.6). We also estimated that the total population declined by 12.58% (9.89-15.03) over the three-year period. This demonstrates that there is a high turnover of free-roaming dogs and that despite neutering a large number of dogs in an annual sterilisation campaign, the decline in population size was modest over a three-year time period. These findings have significant implications for the planning of rabies vaccination campaigns and population management programmes as well as highlighting the need for further research into the demographics of free-roaming, unowned dogs in India.

Delineation of altered brain proteins associated with furious rabies virus infection in dogs by quantitative proteomics

Rabies is a fatal zoonotic disease caused by rabies virus (RABV). Despite the existence of control measures, dog-transmitted human rabies accounts for ˃95% reported cases due to unavailability of sensitive diagnostic methods, inadequate understanding of disease progression and absence of therapeutics. In addition, host factors and their role in RABV infection are poorly understood. In this study, we used 8-plex iTRAQ coupled with HRMS approach to identify differentially abundant proteins (DAPs) of dog brain associated with furious rabies virus infection. Total 40 DAPs including 26 down-regulated and 14 up-regulated proteins were statistically significant in infected samples. GO annotation and IPA showed that calcium signaling and calcium transport, efficient neuronal function, metabolic pathway associated proteins were mostly altered during this infection. Total 34 proteins including 10 down-regulated proteins pertaining to calcium signaling and calcium transport pathways were successfully verified by qRT-PCR and two proteins were verified by western blot, thereby suggesting these pathways may play an important role in this infection. This study provides the map of altered brain proteins and some insights into the molecular pathophysiology associated with furious rabies virus infection. However, further investigations are required to understand their role in disease mechanism. SIGNIFICANCE: Transmission of rabies by dogs poses the greatest hazard world-wide and the rare survival of post-symptomatic patients as well as severe neurological and immunological problems pose a question to understand the molecular mechanism involved in rabies pathogenesis. However, information regarding host factors and their function in RABV infection is still inadequate. Our study has used an advanced quantitative proteomics approach i.e. 8-plex iTRAQ coupled with HRMS and identified 40 DAPs in furious rabies infected dog brain tissues compared to the controls. Further analysis showed that calcium signaling and transport pathway, efficient neuronal functions and metabolic pathway associated brain proteins were most altered during furious rabies virus infection. This data provides a map of altered brain proteins which may have role in furious rabies virus infection. Hence, this will improve our understanding of the molecular pathogenesis of RABV infection.

Defining the volume of rabies immunoglobulins/ rabies monoclonal antibodies requirement for wound infiltration of category III animal exposures - an exploratory study

WHO recommends infiltration of rabies immunoglobulins/rabies monoclonal antibodies as anatomically possible, into or close to all category III animal bite wound(s)/exposures for post exposure prophylaxis. The volume required for wound infiltration depending upon the site/size/severity of wound is yet to be defined for guiding the treating physicians. This study aimed to determine the volume of rabies immunoglobulin/rabies monoclonal antibody required for wound infiltration depending upon the site, size, and severity. A prospective cohort study was conducted including category III animal exposures at the anti-rabies clinic, KIMS hospital and Research Center, Bangalore, India. The volume of rabies immunoglobulins/rabies monoclonal antibodies required for wound infiltration, depending on site, severity, and size was determined. All the subjects were followed for 6 months to demonstrate the safety and clinical efficacy of post exposure prophylaxis. The present study included 717 subjects having 1428 bite wounds. There was a significant difference in the median volume required for wound infiltration based on site, size, and severity of bite wounds. However, on pairwise comparison; the median volume among all the pairs for only wound size was found to be statistically significant. Supportively, a strong positive correlation was seen with the size of wound and volume infiltrated. The volume of rabies immunoglobulin/rabies monoclonal antibodies required for wound infiltration shall be determined according to size of wounds, i.e. 1 ml for <1 cm wound, 3 ml for 1-5 cm wound, and 5 ml for >5 cm wound.

Investigation of protective level of rabies antibodies in vaccinated dogs in Chennai, India

BACKGROUND

Rabies is still endemic in India causing an estimated 20,000 human deaths a year. Free roaming dogs and unvaccinated owned dogs play a major role in the maintenance of the disease. Dog vaccination is the most crucial aspect of rabies prevention and control strategies; therefore vaccine immunogenicity and longevity are important determinants of the efficiency of rabies control efforts.

METHODS

In this study at Madras Veterinary College, India, a total of 297 serum samples were collected from owned dogs that were vaccinated against rabies. Data regarding age, gender, breed, neuter status and last date of vaccination were collected at the time of blood collection. The level of rabies virus neutralising antibodies in the sera of these dogs was measured through rapid focus fluorescence inhibition test. The factors associated with protective level of rabies antibodies in vaccinated dogs were investigated through multivariable regression analysis.

RESULTS

This cross-sectional investigation shows that only 40% (119/297) of the all the dogs in the study showed presence of protective level of anti-rabies antibodies, and 40% (72/180) of the dogs vaccinated within the last year showed presence of protective levels of antibodies causing concern about rabies vaccine quality and its impact on rabies control. The study also shows that older and neutered dogs are more likely to have protective titre among vaccinated dogs, while non-descript breed dogs are less likely to have a protective titre compared to pure breeds.

CONCLUSION

In this study 60% (108/180) of young prima dogs and adult dogs did not show protective levels of antibodies within the year of last rabies vaccination, although they had previous vaccination history. This high percentage of apparent non-responders is a cause of concern of administration, distribution, storage, potency and quality management of vaccines in India.

Knowledge, attitudes and perceptions about rabies among the people in the community, healthcare professionals and veterinary practitioners in Bangladesh

It is crucial to explore knowledge, attitudes and perceptions (KAP) about rabies among the people in the community, the personnel dealing with animal bite management and suspected rabies patients, including humans and animals, to facilitate intervention in improving rabies elimination strategies. In 2016, we conducted an interactive face-to-face survey in three different districts of Bangladesh to understand the extent of KAP towards rabies in the community peoples (CPs), human healthcare professionals (HCPs) and veterinary practitioners (VPs). A set of prescribed questions was employed to measure what proportion of each group possessed sufficient knowledge, positive attitudes and adequate perceptions about rabies. A total of 1133 CPs, 211 HCPs and 168 VPs were interviewed by using a standard questionnaire comprising both closed and open-ended questions. Of the CPs, 49% identified the disease correctly (i.e. rabies is caused by an animal bite or a scratch). Only 29% of the CPs were aware that a wound should be washed immediately with soap and water after an animal bite or a scratch. However, only 49% of the CPs, 65% of the HCPs and 60% of the VPs felt that it is important to consult a physician and receive post-exposure vaccine as the first line of treatment following an animal exposure. Among the HCPs, 23% of the respondents did not possess sufficient knowledge about animal bites as categorised by the World Health Organization (WHO), and 12% of the respondents did not possess the knowledge on how to manage an animal bite properly. Out of 52% of the VPs who previously treated suspected rabid animals, only 29% had a history of taking rabies pre-exposure prophylaxis (PEP). Lack of formal education and rural subsistence were found to largely contribute to poor rabies KAP level among the CPs (P ≤ 0.01). There has been a high demand for proper training to be provided to HCPs and VPs for the effective management of an animal bite incidence in human and animals, respectively. Multi-sectoral collaboration through integrated One Health initiatives including community education, awareness programmes, facilitation of rabies PEP, and dog vaccination as well as its population control are critical in the way forward to control rabies in Bangladesh.

'Stray appetites': a socio-ecological analysis of free-ranging dogs living alongside human communities in Bangalore, India

Across the developing world, humans and free-ranging domestic dogs share common spaces. The relationship between these dogs and humans can range from one of dependence, to apathy, to conflict. Given the high number of humans attacked by dogs every year in India, and the lack of an effective population control strategy, we seek to provide insights into the conflict and propose alternative population management options based on reducing the carrying capacity of the environment. We used a mixed methods approach to understand both ecological and sociological underpinnings of free-ranging dog-human relationships in Bangalore, India. We conducted a photographic capture-recapture survey of free-ranging dogs to estimate population size and linked it to the availability of potential food sources. We also conducted a qualitative survey to assess attitudes of residents towards the dog population. We found that dog population varied from 192 to 1888 per square kilometre across a gradient of housing densities. The density of houses, bakeries and garbage piles were significant predictors of dog population size. Crucially, as low as 10 to 18% of houses supported the large population of dogs, highlighting the need for residents to act responsibly towards the dogs. Further, we found that garbage, although significant, is a secondary food source to household-maintained dogs. Since on the whole, respondents expressed the desire for a reduction in dog population, we suggest decreasing the carrying capacity of the environment by targeting these three food sources.

Estimating the Volume of Equine Rabies Immunoglobulin (eRIG) Required for Local Infiltration in Soft Tissue Animal Bites in Children Using a Wound Size-Based Approach

INTRODUCTION

Post-exposure prophylaxis using rabies immunoglobulin (RIG) is universal recommendation for category III exposures. This study was conducted to determine quantity of RIG used to infiltrate animal bite wounds in relation to longest dimension and area of wound.

METHODS

Children aged 2-18 years reporting within 7 days of category III animal bite were included. eRIG (300 IU/ml) was used in all subjects. A predesigned proforma was filled for clinical and epidemiological details of subjects. Maximum length and width of wounds was measured by using non-stretchable measuring tape. RIG was infiltrated in wounds as per WHO recommendations and volume infiltrated was noted.

RESULTS AND CONCLUSION

A total of 100 subjects were enrolled. The mean (±SD) volume of RIG infiltrated in wounds per unit length was 0.75 (±0.21) ml/cm and per unit area was 3.18 (±1.75) ml/cm2. Regression equations were calculated. Proposed equations y = 0.6x + 0.3, where y is the volume of RIG (ml) and x is the length of the wound (cm) and y = 0.9x + 1.1, where y is the volume of RIG (ml) and x is the area of the wound (cm2) can prove to be a useful tool in RIG volume calculation for primary health care providers.

Clinical aspects of human rabies in the state of Ceará, Brazil: an overview of 63 cases

INTRODUCTION

Rabies is considered one of the most relevant public health problems owing to its high fatality rate and the high number of deaths worldwide.

METHODS

We included patients with human rabies who attended a reference hospital in the state of Ceará during 1976-2019.

RESULTS

Data were available for 63 out of 171 (36.8%) patients. Of these patients, 48 (76.2%) were attacked by dogs. In recent years, wild animals have been the most common aggressor species (marmosets and bats). Only 39 (70%) patients were initially correctly suspected with rabies. Bites were the most frequent exposure (56; 96%), most commonly on the hands (21; 42%) and the head (9; 18.4%). Only 14 (22%) patients had sought medical assistance before the onset of symptoms, and only one completed post-exposure prophylaxis. The most prevalent signs and symptoms included aggressiveness/irritability (50; 79.4%), fever (42; 66.7%), sore throat/dysphagia (40; 63.5%), and myalgia (28; 44.4%). Hydrophobia was present in 17 patients (22.0%).

CONCLUSIONS

Most cases of human rabies in Ceará occurred due to the failure to seek medical assistance and/or the failure of the health system in initiating early post-exposure prophylaxis. There is a need for specific information and education campaigns focusing on the cycle of sylvatic rabies as well as prevention measures. Health professionals should undergo refresher training courses on the signs and symptoms of rabies and on the specific epidemiological features of the disease in Brazil.

Large scale dog population demography, dog management and bite risk factors analysis: A crucial step towards rabies control in Cambodia

Cambodia is a rabid-endemic country. However, data on dog population characteristics are lacking, and there is no national dog vaccination program. We implemented the first extensive door-to-door longitudinal survey in 2 Cambodian provinces, namely Kandal and Battambang, to estimate dog population demographic parameters, identify dog ownership determinants, analyze dog management practices and estimate the yearly cumulative bite incidence and associated factors. During the first session, more than 5000 dogs were recorded and identified. Data on families, dogs and cats characteristics, as well as the number of bites experienced the year before in the family, were recorded. One year later, a second session was performed in both provinces to record missing dogs and the reasons for missing. Age-specific survival rates of the dog populations were computed using Kaplan-Meier estimates. Ownership determinants and bite risk factors were identified using a negative binomial regression model. Dog trade and dog meat consumption were often reported. We estimated high dog-to-human ratios (1:3.8 in Kandal, and 1:3.3 in Battambang). The mean age of dog populations was 26.4 months in Kandal against 24.3 in Battambang, with a survival rate of 52% at 24 months in Kandal (34% only in Battambang). They were no feral dogs, but the large majority of recorded dogs were free roaming. In both provinces, the number of dogs significantly increased in families with children younger than 15, and when the head of the family was a male. The estimated yearly cumulative bite incidences were 2.3 and 3.1% in Kandal and Battambang provinces respectively, and are among the highest in the world. Our survey provides valuable data to focus information programs, parametrize transmission models and identify efficient vaccination strategies to control rabies in Cambodia in the future.

Incidence, Trend, and Mortality of Human Exposure to Rabies in Yemen, 2011-2017: Observational Study

Background

Rabies remains a neglected and poorly controlled disease throughout the developing world, particularly in Africa and Asia, where most human rabies deaths occur.

Objective

This study aimed to describe the epidemiology of rabies exposures, its trend, and its geographical distribution in Yemen.

Methods

Cumulative data from a rabies surveillance system for the period 2011-2017 were obtained from the National Rabies Control Program as paper-based annual reports. Data included the number of persons bitten by a suspected rabid animal, their gender and age, and the result of the animal’s laboratory test. Human cases were defined as those exposed to rabies virus bitten by a suspected rabid animal, exposed to a confirmed rabid animal and then received postexposure prophylaxis (PEP), and deaths occurred after exposure to a confirmed rabid animal after having rabies symptoms during 2011-2017.

Results

From 2011 to 2017, a total of 76,049 persons were bitten by a suspected rabid animal. Of these, 21,927 (28.83%) were exposed to positively confirmed rabid animals and then received PEP, and 295 (0.38%) rabies-related deaths occurred. Of all cases with rabies exposure, 50,882 (66.91%) were males. The most affected age group by animal bites (31,816/76,041, 41.84%), positive exposure (8945/21,927, 40.79%), and rabies deaths (143/295, 48.47%) was 5-14 years. Rabies vaccines and immunoglobulins quantities were least available in 2016 and 2017. The annual incidence rate of exposure to animal bites and rabies exposure was 50 and 14 per 100,000, respectively. The annual mortality rate was 2 per 1,000,000. The highest incidence rate of animal bites was in Dhamar (112 per 100,000) and Ibb (94 per 100,000), whereas the highest incidence of exposed cases was in Amanat Al Asimah (40 per 100,000) and Ibb (37 per 100,000). Mortality rate was the highest in Amanat Al Asimah (6 deaths per 1,000,000) followed by Ibb and Dhamar (4 deaths per 1,000,000 in both).

Conclusions

Rabies remains a worrying health problem in Yemen with higher percentage reported among children and males. Targeting school-age populations by education, communication, and information campaigns about preventive measures is strongly recommended. An electronic system should be introduced to improve reporting. It is important to have a sufficient supply of vaccines and immunoglobulins in control units, especially in the at-risk or impacted governorates. Future studies are suggested to determine incidences and risk factors of disease progression.

Temporal and spatial distributions of animal and human rabies cases during 2012 and 2018, in Tunisia

Rabies is one of the most important zoonosis in Tunisia. In the last 6 years, a dramatic increase in the number of cases in animals had raised concern about the transmission dynamics of rabies and the effectiveness of established control measures. For a better understanding of the epidemiological features of rabies in Tunisia, data on animal and human rabies cases and post-exposure prophylaxis (PEP) protocol, for the period from 2012 to 2018, were analysed to describe the spatial and the temporal distributions of the disease and to guide targeted rabies control measures. Thus, the analysed data have shown that 2,642 animal and 25 human rabies cases were recorded between 2012 and 2018; only few case numbers were reported in wildlife. Time-related distribution showed that the incidence of dog rabies increases over the period of study, from 24,8/100,000 dog population in 2012 to 35,2/100,000 dog population in 2018. Dog seems to be the main reservoir of rabies as it accounted for more than 59% of the animal confirmed cases and the source for more than 80% of the human confirmed cases. Geographical distribution of animal rabies cases revealed the presence of clusters in the North and the Center of Tunisia; only a little number of animal cases were reported in the South. In contrast, the overall human rabies incidence was 0.03 per 100,000 population, during the period of the study. We have found that the incidence of human rabies increases by 13.6% from 2012 to 2015 and drops steadily by 23.41% over the second period (2015 to 2018). A high number of PEP was recorded during the 7-year period, with an average of 360 PEP per 100,000 inhabitants per year. Spatial analysis revealed the presence of clusters of PEP in the Northern and Central governorates. The present study pointed out the need to review the control strategy of rabies in Tunisia and conduct further studies on dog population to provide the basis for a new and efficacious policy of interventions and control program for rabies.

One Health, "Disease X" & the challenge of "Unknown" Unknowns

The emergence of SARS-CoV-2 and its rapid spread globally emphasizes the ever-present threat of emerging and re-emerging infectious diseases. In this review, the pathogen pyramid framework was utilized to identify the "unknown unknowns" associated with the emergence and rapid transmission of novel infectious disease agents. Given that the evolutionary origin of most of the emerging infectious disease agents can be traced to an animal source, we argue the need to integrate the "One Health" approach as a part of surveillance activities. The need for focusing on undertaking global and regional mapping activities to identify novel pathogens is discussed, given that there are an estimated 1.67 million unknown viruses, of which around 631,000 to 827,000 unknown viruses have the capacity to infect human beings. The emerging risks due to the ever-expanding interface between human, animals, both domestic and wildlife, and the environment are highlighted, these are largely driven by the need for safe habitation, growing food, developing infrastructure to support the increasing human population and desire for economic growth. The One Health approach provides a holistic way to address these cross-sectoral issues, by bridging institutional gaps, enumerating priority risk areas and pathogens, and highlighting putative risk factors for subsequent spillover events involving emerging and re-emerging infectious disease pathogens at the human-animal-environment interface.

How geographic access to care shapes disease burden: The current impact of post-exposure prophylaxis and potential for expanded access to prevent human rabies deaths in Madagascar

Background

Post-exposure prophylaxis (PEP) is highly effective at preventing human rabies deaths, however access to PEP is limited in many rabies endemic countries. The 2018 decision by Gavi to add human rabies vaccine to its investment portfolio should expand PEP availability and reduce rabies deaths. We explore how geographic access to PEP impacts the rabies burden in Madagascar and the potential benefits of improved provisioning.

Methodology & principal findings

We use spatially resolved data on numbers of bite patients seeking PEP across Madagascar and estimates of travel times to the closest clinic providing PEP (N = 31) in a Bayesian regression framework to estimate how geographic access predicts reported bite incidence. We find that travel times strongly predict reported bite incidence across the country. Using resulting estimates in an adapted decision tree, we extrapolate rabies deaths and reporting and find that geographic access to PEP shapes burden sub-nationally. We estimate 960 human rabies deaths annually (95% Prediction Intervals (PI): 790–1120), with PEP averting an additional 800 deaths (95% PI: 640–970) each year. Under these assumptions, we find that expanding PEP to one clinic per district (83 additional clinics) could reduce deaths by 19%, but even with all major primary clinics provisioning PEP (1733 additional clinics), we still expect substantial rabies mortality. Our quantitative estimates are most sensitive to assumptions of underlying rabies exposure incidence, but qualitative patterns of the impacts of travel times and expanded PEP access are robust.

Conclusions & significance

PEP is effective at preventing rabies deaths, and in the absence of strong surveillance, targeting underserved populations may be the most equitable way to provision PEP. Given the potential for countries to use Gavi funding to expand access to PEP in the coming years, this framework could be used as a first step to guide expansion and improve targeting of interventions in similar endemic settings where PEP access is geographically restricted and baseline data on rabies risk is lacking. While better PEP access should save many lives, improved outreach, surveillance, and dog vaccination will be necessary, and if rolled out with Gavi investment, could catalyze progress towards achieving zero rabies deaths.

Canine rabies causes an estimated 60,000 deaths each year across the world, primarily in low- and middle-income countries where people have limited access to both human vaccines (post-exposure prophylaxis or PEP) and dog rabies vaccines. Given that we have the tools to prevent rabies deaths, a global target has been set to eliminate deaths due to canine rabies by 2030, and recently, Gavi, a multilateral organization that aims to improve access to vaccines in the poorest countries, added human rabies vaccine to it’s portfolio. In this study, we estimated reported incidence of patients seeking PEP in relation to travel times to clinics provisioning PEP and extrapolate human rabies deaths in Madagascar. We find that PEP currently averts around 800 deaths each year, but that the burden remains high (1000 deaths/year), particularly in remote, hard-to-reach areas. We show that expanding PEP availability to more clinics could significantly reduce rabies deaths in Madagascar, but our results reaffirm that expansion alone is will not achieve the global goal of zero human deaths from dog-mediated rabies by 2030. Combining PEP expansion with outreach, surveillance, and mass dog vaccination programs will be necessary to move Madagascar, and other Low- and Middle-Income countries, forward on the path to rabies elimination.

Serosurveillance of rabies antibodies in dogs in Mumbai region by using indirect ELISA

Rabies is a highly fatal viral infection of the central nervous system affecting all warm-blooded animals including humans. To implement the preventive and control measures, it is important to decide the status of anti-rabies antibodies in dogs. Out of 120 serum samples, 47 (39.2 %) serum samples, showed an antibody titre equal to or above the cut off value of 0.5 IU/ml. The maximum number of dogs showed anti-rabies antibody titres equal to or above the cut-off value of 0.5 IU/ml after <1 month pre-exposure to the rabies vaccine. In 15 serum samples of pet dogs, we observed 13 (86.66 %) dogs with protective anti-rabies antibody titre. Statistical analysis suggests that the age of the animal had no significant effect on anti-rabies antibody titre in vaccinated pet dogs. The overall low seroprevalence of anti-rabies antibody in stray dogs indicates their susceptibility to rabies infection and thus posing a risk of rabies to other animals and humans.

Trends and spatial distribution of animal bites and vaccination status among victims and the animal population, Uganda: A veterinary surveillance system analysis, 2013-2017

Rabies is a vaccine-preventable fatal zoonotic disease. Uganda, through the veterinary surveillance system at National Animal Disease Diagnostics and Epidemiology Centre (NADDEC), captures animal bites (a proxy for rabies) on a monthly basis from districts. We established trends of incidence of animal bites and corresponding post-exposure prophylactic anti-rabies vaccination in humans (PEP), associated mortality rates in humans, spatial distribution of animal bites, and pets vaccinated during 2013–2017. We reviewed rabies surveillance data at NADDEC from 2013–2017. The surveillance system captures persons reporting bites by a suspected rabid dog/cat/wild animal, human deaths due to suspected rabies, humans vaccinated against rabies, and pets vaccinated. Number of total pets was obtained from the Uganda Bureau of Statistics. We computed incidence of animal bites and corresponding PEP in humans, and analyzed overall trends, 2013–2017. We also examined human mortality rates and spatial distribution of animal bites/rabies and pets vaccinated against rabies. We identified 8,240 persons reporting animal bites in Uganda during 2013–2017; overall incidence of 25 bites/ 100,000population. The incidence significantly decreased from 9.2/100,000 in 2013 to 1.3/100,000 in 2017 (OR = 0.62, p = 0.0046). Of the 8,240 persons with animal bites, 6,799 (82.5%) received PEP, decreasing from 94% in 2013 to 71% in 2017 (OR = 0.65, p<0.001). Among 1441 victims, who reportedly never received PEP, 156 (11%) died. Western region had a higher incidence of animal bites (37/100,000) compared to other regions. Only 5.6% (124,555/2,240,000) of all pets in Uganda were vaccinated. There was a decline in the reporting rate (percentage of annual district veterinary surveillance reports submitted monthly to Commissioner Animal Health by districts) of animal bites. While reported animal bites by districts decreased in Uganda, so did PEP among humans. Very few pets received anti-rabies vaccine. Evaluation of barriers to complete reporting may facilitate interventions to enhance surveillance quality. We recommended improved vaccination of pets against rabies, and immediate administration of exposed humans with PEP.

Rabies is a deadly viral disease, that is transmitted mainly by dog bites. Globally at least 59,000 deaths are reported to occur annually- mostly in Sub-Saharan Africa and Asia. However, rabies can be prevented through vaccination of pets (dogs and cats) and administration of rabies vaccine in humans exposed to rabies. In our study we reviewed secondary data of animal bites and rabies captured at the National Animal disease diagnostic epidemiology centre in Entebbe for the period 2013–2017. We found that of 1441 animal bite victims who never received rabies vaccine, only 156 (11%) died hence need for immediate administration of exposed humans with rabies and sensitization of the public about the consequences of animal bites and need for urgent health care. There was a decline in the reporting rate of animal bites during the study period suggesting that evaluation of the barriers to complete reporting may facilitate interventions to enhance surveillance quality. Less than 10% of the pets in the Uganda were vaccinated against rabies hence need for improved vaccination of pets against rabies through appropriated legislation.

Anti-Rabies Vaccine Compliance and Knowledge of Community Health Worker Regarding Animal Bite Management in Rural Area of Eastern India

Background Rabies is a public health problem in developing countries like India accounting for the second-highest number of rabies-related deaths worldwide. Anti-rabies vaccine (ARV) is the only proven and effective way of preventing death in this 100% fatal disease. However, compliance is a real concern. This study aims to assess the compliance of ARV and rabies immunoglobulin (RIG) among the ARV-clinic beneficiaries and also the knowledge of the health workers regarding animal bite management. Methods A cross-sectional study was conducted in an ARV clinic of a community health centre in a rural Odisha (Eastern India) between February and April 2019. All the beneficiaries attending the ARV clinic were followed up for 28 days to assess their ARV and RIG compliance. Data were collected using a pre-designed semi-structured questionnaire and analysis was performed using SPSS v.22 (IBM Corp, Armonk, NY, USA). Proportion was calculated for categorical variables and mean for continuous variables. Chi-square test was applied to test for significance of categorical variables. Results A total of 468 beneficiaries were followed up. More than half (59.8%) of the animal bite victims had a category-II bite, followed by 33.4% having category-III, and 6.8% having a category-I bite. Around three-fourth were exposed to dog bite. Only 52.3% of the patients were compliant with ARV, and 49.4% were compliant with RIG. Knowledge of the health workers regarding wound management was found to be sub-optimal. Conclusion Poor ARV compliance was seen among the beneficiaries. Awareness activities need to be strengthened further to improve health-seeking behaviour. The significant gap in knowledge of the health workers indicates the need for professional training at regular intervals.

Imposing COVID-19 lockdown and reported dog bite cases: An experience from a tertiary antirabies center of North India

The world was taken aback after the corona pandemic started from China and soon engulfed the whole of the world. Strict restrictions were in place since the beginning, and people were confined to their homes; only emergency services were allowed to work. The study's objectives were to see the effect of lockdown on the number of dog bite cases being reported to our antirabies clinic. The study was conducted in the antirabies clinic of the Department of Community Medicine, Government Medical College, Srinagar, Jammu & Kashmir. This study involved a dog bite victim who approached the said clinic during the lockdown, which was implemented in the wake of COVID-19 from March 21, 2020 to June 03, 2020. We included all the dog bite victims living in the Srinagar city and from the adjoining districts who had been bitten by the street dog during the lockdown phase. Over 5 years, 4,670 (73.6%) dog bites among males were reported. The proportion of dog bites among males varies from 72% to 81% in the 5 years. It can be observed that a maximum of 783 (81.1%) dog bites were reported from males during the lockdown period in 2020. Moreover, 2,847 (44.9%) bites were category II dog bites, while 3,392 (55.1%) were category III dog bites. There were fewer dog bites reported at the first, fourth, seventh, eighth, and ninth weeks while there was a little surge in cases on the 2nd, 3rd, 5th, 6th, and 10th week. Lockdown had indirectly reduced the number of dog bite cases reported to the clinic during different lockdown phases than the previous year's data.

The Role of Waste Management in Control of Rabies: A Neglected Issue

Despite being vaccine preventable, the global burden of dog rabies remains significant, and historically it is the rural and marginalized communities in developing countries of Africa and Asia that are most threatened by the disease. In recent years, the developing world has been experiencing unprecedented increases in urbanization, with a correspondingly massive increase in municipal solid waste generation, among other things. Inefficient and inadequate waste collection and management, due to lack of resources and planning, led to significant increases in the volumes of waste on the streets and in open dumps, where it serves as food sources for free-roaming dogs. In this commentary, we discuss examples of poor waste management and the likely impact on rabies control efforts through the sustenance of free-roaming dogs in some dog rabies-endemic countries. We aim to stress the importance of implementing strategies that effectively address this particular issue as an important component of humane dog population management, as it relates to aspirations for the control and elimination of dog rabies per se.

Epidemiological, humanistic and economic burden of dog-mediated rabies in India: a systematic review protocol

Background: Rabies is a neglected zoonotic disease. It is transmitted through the bite of a rabid animal and dog bites are responsible for around 95% of human cases. The disease is almost always fatal after the onset of symptoms. It is an endemic and major public health problem in India with one-third of the global deaths reported from this country. Protocol: This systematic review aims to estimate the epidemiological, humanistic and economic burden of dog-mediated rabies in India. Initially the existence of controlled descriptors in MeSH terms (such as 'Epidemiology', 'Rabies', 'Cost', 'Dog bite', 'Quality of Life', 'India' etc), and their synonyms (key words) was identified in MEDLINE, and were later combined with Boolean operators 'AND' and 'OR' to develop a detailed search strategy. Two independent reviewers will screen the titles and abstracts and select the studies as per the inclusion criteria. The selected studies will be assessed for their quality and risk of bias. Data will be extracted using standardized data extraction tools and will be synthesized for analysis. Disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Discussion: This systematic review will be performed to critically examine relevant literature and report the epidemiological, humanistic and economic burden of dog-mediated rabies in Indian context. The findings will help in estimation of burden of the disease in India and expected to contribute in policy making and planning of the program and interventions in the country. Protocol registration: PROSPERO ID: CRD4202021326.

Epidemiological, humanistic and economic burden of dog-mediated rabies in India: a systematic review protocol

Background: Rabies is a neglected zoonotic disease. It is transmitted through the bite of a rabid animal and dog bites are responsible for around 95% of human cases. The disease is almost fatal after the onset of symptoms. It is an endemic and major public health problem in India with one-third of the global deaths reported from this country. Protocol: This systematic review aims to estimate the epidemiological, humanistic and economic burden of dog-mediated rabies in India. Initially the existence of controlled descriptors in MeSH terms (such as 'Epidemiology', 'Rabies', 'Cost', 'Dog bite', 'Quality of Life', 'India' etc), and their synonyms (key words) was identified in MEDLINE, and were later combined with Boolean operators 'AND' and 'OR' to develop a detailed search strategy. Two independent reviewers will screen the titles and abstracts and select the studies as per the inclusion criteria. The selected studies will be assessed for their quality and risk of bias. Data will be extracted using standardized data extraction tools and will be synthesized for analysis. Disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Discussion: This systematic review will be performed to critically examine relevant literature and report the epidemiological, humanistic and economic burden of dog-mediated rabies in Indian context. The findings will help in estimation of burden of the disease in India and expected to contribute in policy making and planning of the program and interventions in the country. Protocol registration: PROSPERO ID: CRD4202021326.

Barriers and opportunities for canine rabies vaccination campaigns in Addis Ababa, Ethiopia

BACKGROUND

Canine rabies is endemic in Ethiopia and presents a significant burden for both animal and human health. We investigate barriers to dog vaccination in Addis Ababa, Ethiopia. These results can be utilized to improve and target future rabies control efforts.

METHODOLOGY/PRINCIPLE FINDINGS

During May of 2017, dog owners were surveyed during a free canine rabies vaccination programs that utilized both door-to-door (DtD) and central point (CP) vaccination methods. Surveys collected information on preferences for rabies vaccine delivery and were administered in Amharic. A total of 1057 surveys were completed. Of those surveyed, 62.4 % indicated that their dogs had been vaccinated against rabies within the last year. Commonly reported barriers to vaccination were a lack of awareness that dogs required rabies vaccines (18.1 %) and lack of knowledge about where to find vaccine (15.0 %). The median price owners were willing to pay for vaccination was 25 birr ($0.91 USD) and the median distance willing to travel was 1.0 km; however, 48.9 % of those surveyed during DtD were unwilling to travel at all. We identified 3 classes of respondents who were grouped due to their responses by latent class analysis: 'the Unaware', 'the Vaccinators', and 'the Multiple Barriers'.

CONCLUSIONS/SIGNIFICANCE

Although many respondents were willing to pay for rabies vaccine (94.0 %); the preferred cost (median) was less than the actual cost of providing the vaccine. This supports the need for reduced-cost or free vaccine to achieve and sustain the 70 % vaccine coverage target threshold for canine rabies elimination. Additionally, a significant portion (41.5 %) of those surveyed indicated that they were unwilling to travel in order to have their dog vaccinated. The latent class analysis provides useful guidance on how to reach target vaccination. Owners from 'the Unaware' group made up 18.1 % of respondents and their high rate of allowing their dogs to roam identifies them as a prime target for canine health and behavior education. 'The Multiple Barriers' owners reported lower degrees of dog roaming and were substantially more likely to be found by DtD campaigns, possibly because they have limited ability/interest in handling their dogs. These results demonstrate the importance of incorporating DtD vaccination as well as subsidies to maximize vaccine coverage in Addis Ababa.

Multisectoral approach to achieve canine rabies controlled zone using Intervention Mapping: Preliminary results

BACKGROUND

Annually, in India, millions of dog bite cases occur; most of them are inflicted by a stray dog. There are over 25 million dogs in the country. The rate of stray dog vaccination is suboptimal in India. This study aims to develop an intervention strategy, using Intervention Mapping framework, tailored for the target community to achieve canine rabies controlled zone.

METHODOLOGY

This is an exploratory, cross-sectional study conducted at a tertiary care Medical Institute at Jodhpur, Rajasthan, India, from 2018-2019. The semi-structured, In-Depth Discussion was conducted with a multidisciplinary planning group comprising of members from veterinary, health, and administrative sectors. The In-Depth Discussion focused on knowledge regarding complete stray dog vaccination schedule, self-efficacy (to prevent dog bites), challenges, and barriers faced by residents to achieve canine rabies controlled zone. Further, discussion with veterinary stakeholders focused on challenges faced for rigorous implementation of stray dog vaccination and sterilization.

RESULTS

In-Depth Discussion revealed the following challenges: Lack of participation by the study population for canine vaccination, incomplete knowledge about annual canine vaccination schedule, lack of understanding of dog gestures, lack of infrastructure and resources at veterinary hospitals. The majority of the dogs in the study area were stray dogs that were partially or non-vaccinated and non-sterilized. An intersectoral collaboration was achieved between the community members, veterinary stakeholders both private and Non-Governmental organisations, and heath sector. Following which 35 (76.0%) stray dogs were vaccinated, and 17 (35.4%) were sterilized with community support. Burden of dog bite cases also decreased. The stray dog density map was prepared, and community engagement activity on dog gestures was conducted.

CONCLUSION

The present study demonstrates the feasibility of achieving canine rabies controlled zone. When implemented in a phase-wise manner across all Medical and Residential complex, this strategy would ensure achieving canine rabies controlled zone through multi-stakeholder engagement.

Portable Rabies Virus Sequencing in Canine Rabies Endemic Countries Using the Oxford Nanopore MinION

As countries with endemic canine rabies progress towards elimination by 2030, it will become necessary to employ techniques to help plan, monitor, and confirm canine rabies elimination. Sequencing can provide critical information to inform control and vaccination strategies by identifying genetically distinct virus variants that may have different host reservoir species or geographic distributions. However, many rabies testing laboratories lack the resources or expertise for sequencing, especially in remote or rural areas where human rabies deaths are highest. We developed a low-cost, high throughput rabies virus sequencing method using the Oxford Nanopore MinION portable sequencer. A total of 259 sequences were generated from diverse rabies virus isolates in public health laboratories lacking rabies virus sequencing capacity in Guatemala, India, Kenya, and Vietnam. Phylogenetic analysis provided valuable insight into rabies virus diversity and distribution in these countries and identified a new rabies virus lineage in Kenya, the first published canine rabies virus sequence from Guatemala, evidence of rabies spread across an international border in Vietnam, and importation of a rabid dog into a state working to become rabies-free in India. Taken together, our evaluation highlights the MinION's potential for low-cost, high volume sequencing of pathogens in locations with limited resources.

Modelling the challenges of managing free-ranging dog populations

Free-ranging domestic dogs (FRD) are not only vectors of zoonoses of public health concern, but also pose direct threats to humans, livestock, and endangered wildlife. Many developing countries have struggled to control FRD, despite using both lethal and non-lethal methods. India has amongst the highest FRD populations globally and the highest incidences of dog-mediated human rabies, but only deploys Catch-Neuter-Vaccinate-Release (CNVR) for FRD control as a humane alternative to lethal methods, without evidence of it working successfully. Here, we use an agent-based dog population dynamics model to examine the time, effort, financial resources, and conditions needed to successfully control FRD in a typical urban setting. We simulate several scenarios, from an "ideal world" closed population with easily accessible dogs, to a more realistic open population with heterogeneity in catchability of dogs. In only one "best-case" scenario, CNVR resulted in a significant and lasting reduction in FRD, but with vaccination rates peaking only at 35%, which is half the WHO-recommended coverage. The customisable and portable modelling tool that we have developed allows managers to simulate real world processes and understand the expected effort needed to reduce regional dog populations, and assess methods for achieving effective anti-rabies vaccination coverage.