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

[Rabies: Epidemiological update and pre- and post-exposure management]

Rabies is a deadly neurotropic viral infection but is preventable through vaccination. Its impact on human and animal health is often devastating. Despite advances in research and control of this disease, along with an effective vaccine, rabies continues to be a lingering threat in many parts of the world. Its high incidence reinforces the constant need to address it with scientific and public health measures. In this review article, we will explore the most important characteristics of the disease, its distribution, symptoms, prevention methods, and the global efforts that have been made to eradicate this deadly disease. The most recent research and advancements in the field of rabies will also be discussed in an effort to understand and combat this deadly disease more effectively.

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

OBJECTIVES

This study aimed to examine the impact of pertussis on the global, regional, and national levels between 1990 and 2019.

METHODS

Data on pertussis on a global scale from 1990 to 2019 were collected from the 2019 Global Burden of Disease Study. We performed a secondary analysis to report the global epidemiology and disease burden of pertussis.

RESULTS

During the period spanning from 1990 to 2019, pertussis exhibited a steady global decline in the age-standardized incidence rate (ASIR), age-standardized disability-adjusted life years rate (ASYR), and age-standardized death rate (ASDR). Nevertheless, upon delving into an in-depth analysis of various regions, it was apparent that ASIR in southern sub-Saharan Africa, ASYR and ASDR in high-income North America, and ASDR in Western Europe and Australasia, were witnessing an upward trajectory. Moreover, a negative correlation was observed between the Socio‑demographic Index (SDI) and burden inflicted by pertussis. Notably, the incidence of pertussis was comparatively lower in men than in women, with 0-4-year-olds emerging as the most profoundly affected demographic.

CONCLUSION

The global pertussis burden decreased from 1990 to 2019. However, certain regions and countries faced an increasing disease burden. Therefore, urgent measures are required to alleviate the pertussis burden in these areas.

Dog ecology and rabies control including canine vaccination coverage: Impacts from a survey in Madagascar

BACKGROUND

Rabies virus (RABV; species Lyssavirus rabies) is causing one of the oldest zoonotic diseases known to mankind, leading to fatal encephalomyelitis in animals and humans. Despite the existence of safe and effective vaccines to prevent the disease, an estimated 99% of human rabies deaths worldwide are caused by dog-mediated rabies with children at the highest risk of infection. Rabies has been endemic in Madagascar for over a century, yet there has been little research evaluating local knowledge and practices impacting on the rabies control and prevention. Thus, this study was undertaken to better understand the dog ecology including canine vaccine coverage and to assess knowledge and practices of dog owners and veterinarians.

METHODOLOGY

A cross-sectional study was conducted among 123 dog-owning households in thirteen fokontanys in Mahajanga from July 4 to September 13, 2016. Single and multi-member dog-owning households in the study area on the day of the interview were eligible for inclusion and purposively selected with the support of a local guide. The survey included a household questionnaire capturing information on the dog's demographics, husbandry practices, knowledge and practices towards rabies and its control measures; the dog ecology questionnaire collected dog characteristics, vaccination status and husbandry practices. All households that reported a dog bite incident, were invited to participate in a dog bite questionnaire. In addition, direct observations of roaming dogs were conducted to assess dog population demographics and to document behavioural characteristics. Two veterinarians were purposively selected and took part in an interview during the survey period, providing information on rabies control activities, including dog-care practices in the area. Descriptive and inferential data analyses were performed using Epi Info version 7.1.5.0 (CDC Atlanta, USA).

RESULTS

We recorded a total of 400 dogs, of which 338 (84.5%) were owned amongst 123 households. More than half (67.8%) of owned dogs were between 1 to 5 years old and 95.6% were kept for guarding purposes. 45% of the surveyed dogs had free access to roam outside the premises. The majority (85.4%) of dog owners were knowledgeable that a dog bite could potentially transmit RABV to humans. 19 dog bites were reported and of these 73.6% were caused by the owner's or a neighbour's dog. In 6 of the 19 cases, children between 7 and 15 years of age were the victims. Dog vaccination coverage against rabies was 34% among owned dogs. Of the participants aware of a veterinarian, the majority (55/82) indicated that they accessed veterinarian services at irregular intervals. The main obstacles to vaccinations cited by dog owners were limited financial resources and difficulty accessing veterinary care.

CONCLUSION

This study contributes to enhanced understanding of the dog ecology including canine vaccine coverage as well as knowledge and practices of dog owners in Madagascar. Most dogs in the study area were accessible for preventive vaccination through their owners, however only one third of the investigated canine population was vaccinated against rabies. Concerted national efforts towards rabies prevention and control should aim to address financial challenges and access to veterinary services.

Assessment of respondents' knowledge, attitudes, and practices toward rabies and associated risk factors in Shone Town, Southern Ethiopia

IMPORTANCE

Rabies is a neglected tropical viral disease most often transmitted through the bite of an infected animal.

OBJECTIVE

This study assessed the level of knowledge, attitudes, and practices of the Shone Town community toward rabies.

METHODS

A survey-based cross-sectional study was conducted in Shone town, Ethiopia, from November 2022 to April 2023. Woreda was selected purposefully, while Kebeles and the study populations were selected by simple random sampling. Four hundred and sixteen respondents were interviewed using a semi-structured questionnaire.

RESULTS

All respondents had heard about rabies from different sources, with the majority hearing from informal sources (62%). Approximately 51.9%, 0.7%, and 47.4% of individuals were aware of saliva contact, rabid animal bites, and both as means of transmission, respectively. The survey showed that 64.4% of participants knew the 100% fatal nature of rabies once the clinical signs developed, and 35.6% did not. Approximately 51.4% of respondents agreed that killing stray dogs was an effective method for rabies prevention. In this study, 72.6% of the respondents had contact with pets, and 36.8% of the interviewees had vaccinated their dogs. Only the educational level (p = 0.03) was associated with knowledge of the transmission route. Age (p = 0.04) and educational level (p = 0.01) had a statistically significant association with knowledge of the risk of not vaccinating dogs.

CONCLUSIONS AND RELEVANCE

A lack of formal education in the communities, low levels of education, and the majority of respondents acquiring their knowledge from unofficial sources are important contributors to the low levels of awareness.

Bovine rabies cases in Ecuador: a retrospective cross-sectional observational study (2007 to 2020)

The hematophagous bats are usually the main reservoir of sylvatic rabies, being one of the most important viral zoonoses affecting humans and livestock in Latin America. Despite the most countries have already studied spatio-temporal distribution of bovine rabies, however, in Ecuador, little has been reported about the state of rabies in the country. Aiming to this objective, a descriptive observational study was realized from 2007 to 2020 based on the formal reports by WAHI-OIE and surveillance of bovine rabies retrieved from its official website. During the study period in Ecuador, some 895 cases of rabies were confirmed in cattle. In addition, in the total of bovine rabies cases seen in Andean and Coast regions (185 effected bovines), Loja and Esmeraldas had 95 (6.16% cases per 10,000 animals) and 51 (1.7% cases per 10,000 animals), respectively. Furthermore, the Amazon region indicated higher rabies cases in cattle than to the observed in other regions (710 rabies cases) while it was highly fluctuating with respect to the years (9.74 to 42.82% cases per 10,000 animals). However, Zamora (292 rabies cases), Orellana (115 rabies cases) and Sucumbíos (113 rabies cases) yielded the highest incidence rates than other provinces (9 to 42% cases per 10,000 animals). Based on this evidence, it has been fundamental to assess the current national program for preventing and control of the sylvatic rabies, being also necessary to include concept of the ecology of the vampire bat. Regardless of these results, vaccination is vital for control programs to prevent rabies in livestock and need to be widely increased for limiting their geographic and temporal spread.

Real-world evidence of rabies post-exposure prophylaxis in Serbia: Nation-wide observational study (2017-2019)

BACKGROUND

Rabies remains a deadly zoonotic disease, primarily prevalent in Eastern European countries, with a significant global burden in Asia and Africa. Post-exposure prophylaxis (PEP) is critical to prevent clinical rabies. Serbia, a country with a relatively low animal rabies incidence, has been implementing a 4-dose Essen PEP regimen for 13 years. This real-world study aimed to assess the effectiveness of the 4-dose Essen regimen, considering demographic and clinical factors, after WHO Category III exposure.

METHOD

The study included 601 patients who received the 4-dose Essen PEP and 79 who received an additional 5th dose.

RESULTS

Age emerged as a critical factor influencing seroconversion rates after the 4-dose regimen, with older individuals exhibiting lower RVNA titers. Logistic regression indicated a 3.18% decrease in seroconversion odds for each added year of age. The Cox proportional hazards mixed model highlighted age-related risks, with age groups 45-60 and 75-92 at the highest risk of non-seroconversion. Human Rabies Immune Globulin (HRIG) administration was associated with lower RVNA values after the 4-dose regimen, suggesting interference with vaccine immunogenicity among people who received larger doses of HRIG.

CONCLUSIONS

This study provides valuable real-world evidence for rabies PEP in a non-homogeneous population with potential comorbidities. The results underscore the importance of optimizing PEP strategies, particularly in older individuals, and reconsidering HRIG dosing to improve seroconversion rates.

Human rabies encephalomyelitis in the background of rabies outbreak in animals in Gelephu, Bhutan, 2023: a case report

BACKGROUND

Rabies continues to pose significant public health challenges in many developing countries including Bhutan. A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals. We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting.

CASE PRESENTATION

A 35-year-old male presented with intermittent fever, bilateral lower limb weakness that was rapidly progressive, urinary incontinence with episodes of palpitations and sweating. He had sustained a Category III bite on the right lower thigh with four bite marks, inflicted by a stray dog. He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine. On initial examination, the patient was in distress but cooperative for the interview. He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations, but with normal capillary blood glucose. In the lower limb, the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T10 level. He had hyperaesthesia below T8, hydrophobia, aerophobia and photophobia. He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles, neck and face muscles. He had altered sensorium and desaturation for which he required mechanical ventilation. Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva. Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum. He received Human Rabies Immunoglobulin after admission. He was managed in the intensive care unit and died 23 days later. After this case was notified, a rapid response team was deployed in the field, and uncovered rabies outbreak in animals in the locality.

CONCLUSIONS

This case called for a serious evaluation of the country's efforts in achieving zero rabies deaths by 2030. The management of this case identified several critical areas of context-specific interventions in Bhutan. There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases.

You Are Not Welcome! A Media Analysis of Risk Factors, Prevalence and Management of Free-Roaming Dogs in Iran

History has witnessed a long-term relationship between humans and animals. Historical documents and modern findings prove that humans' needs to use animals for companions or services are commonplace in many parts of the world, leading to the domestication of certain animals. Yet, modern societies have degraded many natural habitats for wildlife, confining them to small patches of landscapes or urban areas. Whether a domesticated/free-roaming animal or a wild species, their close contact with humans can create cumbersome situations for both species. This paper explores a link between online media content and on-the-ground efforts to manage free-roaming dogs as a rare case study. As indicated by news articles, the municipal costs of managing free-roaming dogs in Iranian cities have increased, and this can potentially derail the control of such dogs in the long run. This paper lays out pivotal factors for recent increasing human-animal encounters, which have led to many challenges (e.g., rabies) across cities in Iran. We show that some urban features (e.g., topography) can influence the presence and behaviours of free-roaming animals in the cities. The findings of this paper can be related to other developing countries where the plague of rabies is rising.

Immune-adjuvant effect of vitamin A and probiotics supplementation on humoral response to cell culture rabies vaccine in rabbits

This study was carried out to evaluate the effects of vitamin A (Vit A) and probiotic co-supplementation with rabies vaccine on humoral immune response in New Zealand white (NZW) rabbits. For this experiment, 54 rabbits were randomized into six experimental and three control groups. Mixed cultures of commercial probiotics supplements and a dose of Vit A were administered to each animal. Results were compared with the control group fed with only basal diet. Animals in different treatment groups showed significantly higher sero-conversions against rabies vaccine. There was a significant increase (p < 0.001) in the titers of rabies antibodies in all treatment groups on 14th and 35th days than control C3 group. Both commercial probiotics irrespective of brand increase the humoral immune response of rabbits against rabies vaccine. The mean titer values of all groups G1-G6 and sub-controls (C1, C2) were generally above 3.6 EU/ml on day 14th and between 3.7 and 3.9 EU/ml, showing highest sero-conversion on 35th day than mean titer of C3 control = 3.091 and 3.505 EU/ml respectively on both days. The maximum titer values were obtained with the addition of organic carrots to the daily diet. These results suggest that simple dietary interventions using probiotics and Vit A in natural form may enhance the efficacy of rabies vaccine in the host. These cost-effective strategies can be applied for getting higher yields of polyclonal antibody production in animal models, thus providing promising means of improving the final product yield and can be adopted easily by the manufacturers.

Epidemiologic Aspects of Animal Bite, Rabies, and Predictors of Delay in Post-exposure Prophylaxis: A National Registry-based Study in Iran

BACKGROUND

The increasing trend in animal bites and rabies in recent years makes the disease a public health concern in Iran. The objectives of the current study were to investigate the epidemiologic aspects of the animal bite and determine the associated risk factors of the delay in initiation of post-exposure prophylaxis (PEP) against rabies in Iran.

STUDY DESIGN

National registry-based cross-sectional study.

METHODS

This study included all registered cases of animal bites between March 2021 and March 2022 at the Ministry of Health and Medical Education in Iran. We retrieved epidemiologic data on person, time, place, and PEP outcome.

RESULTS

A total of 260470 animal bite cases (approximately 334 per 100000 populations, and 11 deaths) were registered during the study period. About 77.2% of them were reported in males, 4.3% in children aged less than 5 years, 56.4% occurred in urban areas, 98% in domestic animals, and mostly in north and northeast areas of Iran. Additionally, 2.8% of cases had a delay of more than 48 hours in the initiation of PEP. Significant determinants of the increase in delay were female gender (OR=1.43, 95% CI: 1.36, 1.51, P<0.001), foreign nationality (OR=1.19, 95% CI: 1.01, 1.12, P=0.001), rural residence (OR=1.07, 95% CI: 1.01, 1.12, P=0.010), and the wild animals (OR=1.22, 95% CI: 1.12, 1.34, P<0.001).

CONCLUSION

The observed frequency of animal bites in a year indicates a serious public health concern and the need for targeted interventions, especially in at-risk areas and vulnerable populations.

Rabies in a postpandemic world: resilient reservoirs, redoubtable riposte, recurrent roadblocks, and resolute recidivism

Rabies is an ancient disease. Two centuries since Pasteur, fundamental progress occurred in virology, vaccinology, and diagnostics-and an understanding of pathobiology and epizootiology of rabies in testament to One Health-before common terminological coinage. Prevention, control, selective elimination, and even the unthinkable-occasional treatment-of this zoonosis dawned by the twenty-first century. However, in contrast to smallpox and rinderpest, eradication is a wishful misnomer applied to rabies, particularly post-COVID-19 pandemic. Reasons are minion. Polyhostality encompasses bats and mesocarnivores, but other mammals represent a diverse spectrum of potential hosts. While rabies virus is the classical member of the genus, other species of lyssaviruses also cause the disease. Some reservoirs remain cryptic. Although global, this viral encephalitis is untreatable and often ignored. As with other neglected diseases, laboratory-based surveillance falls short of the notifiable ideal, especially in lower- and middle-income countries. Calculation of actual burden defaults to a flux within broad health economic models. Competing priorities, lack of defined, long-term international donors, and shrinking local champions challenge human prophylaxis and mass dog vaccination toward targets of 2030 for even canine rabies impacts. For prevention, all licensed vaccines are delivered to the individual, whether parenteral or oral-essentially 'one and done'. Exploiting mammalian social behaviors, future 'spreadable vaccines' might increase the proportion of immunized hosts per unit effort. However, the release of replication-competent, genetically modified organisms selectively engineered to spread intentionally throughout a population raises significant biological, ethical, and regulatory issues in need of broader, transdisciplinary discourse. How this rather curious idea will evolve toward actual unconventional prevention, control, or elimination in the near term remains debatable. In the interim, more precise terminology and realistic expectations serve as the norm for diverse, collective constituents to maintain progress in the field.

Rabies post-exposure prophylaxis of international travellers - Results from two major German travel clinics

BACKGROUND

Travel to regions with rabies risk has increased. However, data on adequate rabies post exposure prophylaxis (PEP) abroad is scarce. The aim of this study was to assess the appropriateness of medical management following suspected rabies exposure (SRE) in international travellers.

METHOD

A cross-sectional questionnaire-based study in returning travellers with reported SRE who sought post-exposure medical care was conducted in two large German travel clinics.

RESULTS

The 75 included SRE cases had a median age of 34 years (range 26-43) and showed a female predominance (59%, 44/75). Most participants returned from Asia (47%, 34/72). About 28% had received pre-exposure prophylaxis (PrEP, ≥2 vaccine doses) (20/71). In 51% the animal was actively approached (34/67). All patients had category II/III exposure according to the World Health Organization (65% category III, 49/75). With 78% (52/67), most patients cleaned the wound after SRE; 36% (24/67) used water and soap. Only 57% (41/72) of participants sought medical care during their trip. Overall, 45% (33/74) received rabies vaccination abroad which corresponds to 80% out of those who sought healthcare (33/41).

CONCLUSIONS

Awareness for appropriate first aid and the urgency of seeking timely professional treatment including PEP after an SRE seems to be insufficient in German travellers. Travel practitioners need to educate travellers about rabies risk, prevention measures and the correct behaviour after SRE including adequate wound treatment and seeking immediate medical help for PEP. PrEP should be offered generously especially to travellers with high rabies-exposure risk and those visiting areas with limited healthcare access.

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 [...]