Patterns of rabies occurrence in Bhutan between 1996 and 2009

Rabies in Cats-An Emerging Public Health Issue

Human rabies cases today are predominantly associated with infection from rabid domestic dogs. Unlike dogs, a common global reservoir species that perpetuates rabies viruses (RABV) within their populations, domestic cats are much less frequently reported or vaccinated. Epidemiologically, cats are important vectors of lyssaviruses but are not viral reservoirs. Typically, cats are incidental hosts only, infected with the predominant lyssavirus in their geographic locale. Human cases associated with rabid cats have occurred in Africa, Asia, Europe and throughout the Americas. As adept, solitary hunters, wild and domestic felids are at risk of lyssavirus infection based upon interactions with infected prey, such as bats, or from transmission by other mesocarnivores, such as rabid dogs, foxes, jackals, raccoons, and skunks. Current veterinary vaccines provide safe and effective immunity in cats against phylogroup I lyssaviruses, such as RABV, but not against divergent lyssaviruses in phylogroups II-IV. With the focus upon the global elimination of canine rabies, the emergence of rabies in cats represents a concerning trend. Clearly, education about the occurrence of rabies in cats needs to be improved, as well as the routine vaccination of cats to reduce the associated risks to public health, agriculture, and conservation biology from a One Health perspective.

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.

Patterns of Animal Rabies Prevalence in Northern South Africa between 1998 and 2022

Rabies is endemic in South Africa and rabies cycles are maintained in both domestic and wildlife species. The significant number of canine rabies cases reported by the World Organization for Animal Health Reference Laboratory for Rabies at Onderstepoort suggests the need for increased research and mass dog vaccinations on specific targeted foci in the country. This study aimed to investigate the spatiotemporal distribution of animal rabies cases from 1998 to 2017 in northern South Africa and environmental factors associated with highly enzootic municipalities. A descriptive analysis was used to investigate temporal patterns. The Getis-Ord Gi statistical tool was used to exhibit low and high clusters. Logistic regression was used to examine the association between the predictor variables and highly enzootic municipalities. A total of 9580 specimens were submitted for rabies diagnosis between 1998 and 2022. The highest positive case rates were from companion animals (1733 cases, 59.71%), followed by livestock (635 cases, 21.88%) and wildlife (621 cases, 21.39%). Rabies cases were reported throughout the year, with the majority occurring in the mid-dry season. Hot spots were frequently in the northern and eastern parts of Limpopo and Mpumalanga. Thicket bush and grassland were associated with rabies between 1998 and 2002. However, between 2008 and 2012, cultivated commercial crops and waterbodies were associated with rabies occurrence. In the last period, plantations and woodlands were associated with animal rabies. Of the total number of municipalities, five consistently and repeatedly had the highest rabies prevalence rates. These findings suggest that authorities should prioritize resources for those municipalities for rabies elimination and management.

Understanding the incidence and timing of rabies cases in domestic animals and wildlife in south-east Tanzania in the presence of widespread domestic dog vaccination campaigns

The "Zero by 30" strategic plan aims to eliminate human deaths from dog-mediated rabies by 2030 and domestic dog vaccination is a vital component of this strategic plan. In areas where domestic dog vaccination has been implemented, it is important to assess the impact of this intervention. Additionally, understanding temporal and seasonal trends in the incidence of animal rabies cases may assist in optimizing such interventions. Data on the incidence of probable rabies cases in domestic and wild animals were collected between January 2011 and December 2018 in thirteen districts of south-east Tanzania where jackals comprise over 40% of reported rabies cases. Vaccination coverage was estimated over this period, as five domestic dog vaccination campaigns took place in all thirteen districts between 2011 and 2016. Negative binomial generalized linear models were used to explore the impact of domestic dog vaccination on the annual incidence of animal rabies cases, whilst generalized additive models were used to investigate the presence of temporal and/or seasonal trends. Increases in domestic dog vaccination coverage were significantly associated with a decreased incidence of rabies cases in both domestic dogs and jackals. A 35% increase in vaccination coverage was associated with a reduction in the incidence of probable dog rabies cases of between 78.0 and 85.5% (95% confidence intervals ranged from 61.2 to 92.2%) and a reduction in the incidence of probable jackal rabies cases of between 75.3 and 91.2% (95% confidence intervals ranged from 53.0 to 96.1%). A statistically significant common seasonality was identified in the monthly incidence of probable rabies cases in both domestic dogs and jackals with the highest incidence from February to August and lowest incidence from September to January. These results align with evidence supporting the use of domestic dog vaccination as part of control strategies aimed at reducing animal rabies cases in both domestic dogs and jackals in this region. The presence of a common seasonal trend requires further investigation but may have implications for the timing of future vaccination campaigns.

Animal rabies epidemiology in Nepal from 2005 to 2017

Background and Aim: Animal rabies is endemic in Nepal, and it occurs in two forms. Although governmental and non-governmental agencies are working toward the control of rabies by mass dog vaccination and stray dog population management, there is still massive number of rabies incidence reported to the reference veterinary laboratory, Nepal. Therefore, this study aimed to assess animal species, temporal, regional, and agro-ecological distribution patterns of animal rabies in Nepal from 2005 to 2017. Materials and Methods: The epidemiological data on animal rabies from the period of 2005 to 2017 were obtained from the Central Veterinary Laboratory, Tripureshwor, Kathmandu, Nepal. The laboratory-confirmed rabies cases were analyzed according to animal species, temporal, regional (developmental zones), and agro-ecological distributions. In addition, descriptive statistics were used to evaluate the distribution patterns of rabies. Results: From 2005 to 2017, a total of 2771 suspected rabies cases in animals were reported to The Central Veterinary Hospital, Kathmandu. Of which, 1302 were found laboratory-confirmed cases. The rabies cases were most commonly reported and confirmed in dogs followed by other domestic animals. The high occurrences were recorded between 2005 and 2007. However, the incidence was increased during 2016 and 2017. The highest number of rabies cases was recorded in the eastern development zone, and the least number in the central zone at regional level. Likewise, it was highest in the Terai (plain) region and lowest in mountainous areas at agro-ecological zones. The findings also revealed that the occurrences of rabies significantly differed among seasons. Conclusion: Rabies is present in Nepal throughout the year and all seasons with seasonal variation. Among the animal species, dogs are the primary animals affected with rabies followed by cattle and other domestic animals. At the regional level, eastern development zone had the highest incidence and Central development zone recorded the least. Similarly, the Terai region had the highest incidence rates, and the least overall prevalence rate was observed in mountainous regions among agro-ecological zones. Therefore, the government should implement the strict enforcement of mass dog vaccination and dog population management through one health approach to control rabies incidence in the country.

Probable rabies in a child in a Bhutanese town bordering India, 2020

Rabies is a neglected tropical disease that causes mortality and high economic burden in many developing countries. Rabies is a vaccine-preventable disease if timely post-exposure prophylaxis is available after animal exposure. The control of rabies requires limiting the transmission of the virus in the animal reservoir, effective public health measures to control outbreaks and increasing accessibility and uptake of rabies post-exposure prophylaxis. Bhutan is a small Himalayan country where rabies is endemic. In this article, we describe the death of a 3-year-old female child due to probable rabies in a Bhutanese village located along the border with India. The child had a furious form of rabies with encephalitic syndrome developing 57 days after a category III dog bite on the chest. The child was managed at a district hospital with the available resources. This is the first rabies death in Bhutan in the last 5 years and the 18^th since 2006. This case report focuses on the efforts required to increase the timely uptake of post-exposure prophylaxis in a free healthcare system in Bhutan.

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.

Knowledge, attitude, and practice about rabies prevention and control: A community survey in Nepal

Background and Aim:

Rabies is a fatal zoonosis caused by RNA virus belonging to genus Lyssavirus. Nepal is one of the endemic countries in South Asia for rabies. This study was conducted to better understand the knowledge, attitude, and practice (KAP) of Nepalese community toward rabies across five developmental zones of the country.

Materials and Methods:

The cross-sectional study was carried out by face-to-face interview using structured questionnaires among 5000 respondents of five cities representing each of the five developmental regions of Nepal by adopting random cluster sampling procedure. The respondents were classified into four categories, including gender, age, education, and social status. The responses for KAP variables were analyzed using descriptive and Chi-square test.

Results:

The male and younger age respondents with higher education and social status were found more knowledgeable than their counterparts in terms of knowledge variables, including cause of rabies, mode of transmission, clinical signs, treatment, and preventive measures of this fatal disease. Similar findings were observed for attitude and practice variables such as vaccination practice, dog sterilization, health-seeking behavior, first aid practice, and use of first aid materials after dog bites. Some respondents in elderly age group still preferred to use traditional and local methods, which were application of turmeric powder and shrubs to cure dog bites rather than seeking medical facilities.

Conclusion:

There is a strong need for rabies awareness programs in the community targeting females, school, and college-level students, older age groups, and economically marginalized communities. The awareness materials need to focus on particular topics such as the risk of rabies, modes of transmission, the importance of first aid, health-seeking behavior following dog bite injuries, and practice preventive measures for their pets and community dogs.

Knowledge and Perception of Rabies among School Children in Rabies Endemic Areas of South Bhutan

Rabies is endemic in southern Bhutan and children are the frequent victims of dog bites. We surveyed the knowledge, attitude, and practices on rabies among school children in three schools located in southern Bhutan. A total of 701 students (57.9% female, 42.1% male) with an age range of 12–21 years (mean: 15 years) participated in the survey, of which 98.2% had heard about rabies. Most of the students demonstrated a good level of knowledge (59.7%) and a favorable perception towards rabies (57.7%). Multivariable logistic analysis revealed the relation between knowledge and the awareness campaign (OR:1.5, 95% CI: 1.1–2.1). Similarly, higher grades of students (OR:1.9, 95%CI: 1.3–2.9) and employed mothers of the students (OR: 1.6, 95% CI: 1.0–2.7) were associated with more favorable perceptions. However, some knowledge gaps were identified in this study, such as students not being able to clearly mention the susceptible hosts of rabies, transmission routes, clinical signs, and prevention and control options. Therefore, regular awareness programs on rabies are necessary among school children in Bhutan.

Evaluation of the Worldwide Occurrence of Rabies in Dogs and Cats Using a Simple and Homogenous Framework for Quantitative Risk Assessments of Rabies Reintroduction in Disease-Free Areas through Pet Movements

Dog and cat rabies cases imported from rabies enzootic countries represent a major threat for areas that have acquired rabies-free status and quantitative risk analyses (QRAs) are developed in order to assess this risk of rabies reintroduction through dog and cat movements. Herein we describe a framework to evaluate dog and cat rabies incidence levels in exporting countries along with the associated uncertainty for such QRAs. For enzootic dog rabies areas (EDRAs), we extended and adapted a previously published method to specify the relationship between dog rabies vaccination coverage and canine rabies incidence; the relationship between dog and cat rabies incidences; and then to predict annual dog and cat rabies incidences. In non-enzootic dog rabies areas (nEDRAs), we provided annual incidence based on declared dog and cat rabies cases. For EDRAs, we predicted an annual incidence potentially greater than 1.5% in dogs and about ten times lower in cats with a high burden in Africa and Asia but much lower in Latin America. In nEDRAs, the occurrence of rabies was lower and of similar magnitude in dogs and cats. However, wildlife could still potentially infect dogs and cats through spillover events. This framework can directly be incorporated in QRAs of rabies reintroduction.

Evaluation of a rapid immunochromatographic test kit to the gold standard fluorescent antibody test for diagnosis of rabies in animals in Bhutan

Background

Rabies kills approximately 59,000 people each year worldwide. Rapid and accurate diagnosis of rabies is important for instituting rapid containment measures and for advising the exposed people for postexposure treatment. The application of a rapid diagnostic tests in the field can greatly enhance disease surveillance and diagnostic activities, especially in resource poor settings. In this study, a total of 179 brain tissue samples collected from different rabies suspect animal species (113 dogs, 50 cattle, 10 cats, 3 goats, 2 horses, and 1 bear) were selected and tested using both rapid immunochromatographic kit and the reference standard fluorescent antibody test (FAT). We evaluated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of a rapid antigen detection test kit produced by BioNote, Inc. (Hwaseong-si, Korea) relative to a FAT for its fit-for-purpose for confirmation of clinical cases of rabies for early response and enhancing rabies surveillance.

Results

Among 179 samples examined in this study, there was a concordance in results by the rapid test and FAT in 115 positive samples and 54 negative samples. Test results were discordant in 10 samples which were positive by FAT, but negative (false negative) by rapid kit. The rapid test kit showed a sensitivity of 92% (95% CI: 85.9–95.6) and specificity of 100% (95% CI: 93.4–100) using FAT as the reference standard. The positive and negative predictive values were found to be 100% (95% CI:96.7–100) and 84.4% (95% CI: 73.6–91.3), respectively. Overall, there was 94.4% (95% CI: 90–96.9) test agreement between rapid test and FAT (Kappa value = 0.874) with a positive percent agreement and negative percent agreement of 92 and 100%, respectively.

Conclusions

Our finding demonstrated that the rapid test kit (BioNote) can be used for rabies surveillance and confirming clinical case of rabies in animals for making rapid decisions particularly controlling rabies outbreaks in resource poor settings.

Comparison of antibody titres between intradermal and intramuscular rabies vaccination using inactivated vaccine in cattle in Bhutan

In developing countries, the cost of vaccination limits the use of prophylactic rabies vaccination, especially in cattle. Intradermal vaccination delivers antigen directly to an area with higher number of antigen-presenting cells. Therefore, it could produce equivalent or higher antibody titres than conventional intramuscular vaccination even when a lower dose is given. This study aimed to compare the antibody response in cattle vaccinated intramuscularly with 1mL of inactivated rabies vaccine (Raksharab, Indian Immunologicals) against intradermally vaccinated cattle with 0.2mL of the same vaccine. The study was conducted in Haa province of Bhutan where rabies is not endemic. One hundred cattle from 27 farms were selected for the study. Virus neutralising antibody (VNA) response was measured using the fluorescent antibody virus neutralisation test on the day of vaccination (day 0) and 14, 30, 60 and 90 days later. Overall, 71% of intradermally vaccinated cattle and 89% of the intramuscularly vaccinated cattle produced an adequate response (≥0.5IU/mL). On days 14 and 30 post vaccination fewer cattle (P<0.02) in the intradermal group had adequate titres with 36% and 58%, respectively, having titres ≥0.5 IU/mL compared to the equivalent figures of 78% and 77% in the intramuscular group. The mean VNA titres were lower for the intradermal group than intramuscular group (p<0.001) with the mean difference being > 0.6 IU/mL. Although low dose intradermal vaccination did produce a detectable antibody response, it was inferior to intramuscular vaccination. Thus, although intradermal vaccination has the potential to reduce the cost of vaccination by reducing the dose required, this study showed that a single dose of 0.2 mL intradermally was inferior to an intramuscular dose of 1 mL. Further research evaluating dose and dose regimen is needed before intradermal vaccination using the Raksharab rabies vaccine can be recommended in cattle.

Epidemiological Features of Human Cases After Bites/Scratches From Rabies-suspected Animals in Zenica-Doboj Canton, Bosnia and Herzegovina

OBJECTIVES

To determine the epidemiological features of patients and animals after bites/scratches from rabies-suspected animals in Zenica-Doboj Canton, Bosnia and Herzegovina.

METHODS

Data from all patients (and the causative animals) admitted to the Antirabies Service of the Institute for Health and Food Safety Zenica in the 2009-2017 period were analyzed, including age, sex, anatomical site of the bite/scratch, animal type (stray/owned/wildlife), veterinary observations of the animal, and whether antirabies post-exposure prophylaxis (PEP) was indicated and/or administered.

RESULTS

In total, 1716 patients were admitted. Bites/scratches were most frequently recorded during April and May (n=181, 10.5% and n=163, 9.5%, respectively). The persons admitted were mostly from the Zenica municipality (n=1278, 74.5%; incidence: 11.55/ 1000), which is 66.6% urbanized. Males were more frequently represented (n=1089, 63.6%). The patients were mostly 50-64 and 25-49 years of age (n=425, 24.7% and n=390, 22.7%, respectively). Dog bites were the most common cause (n=1634, 95.1%, of which n=1258, 77.0% were caused by stray dogs). PEP was indicated for 997 (58.1%) patients. Only 340 (19.9%) animals underwent veterinary observations (3.1% of stray and 76.1% of owned animals). The largest number of injuries were presented at lower extremities, 1044 (60.8%) cases.

CONCLUSIONS

Zenica-Doboj Canton is a rabies-free region. Due to the high rate of stray animals not undergoing veterinary observations, the non-existence of a unique dog registry, and the consequent lack of information about stray animals in terms of number, vaccination, neutering, and euthanasia, there is an urgent need for improving the prevention and control of rabies within the One Health framework.

A community-based knowledge, attitude, and practice survey on rabies among cattle owners in selected areas of Bhutan

Rabies remains a disease of significant zoonotic and economic concern in rabies endemic areas of Bhutan. Rabies outbreaks in livestock threaten the livelihoods of subsistence farming communities and pose a potential public health threat. As a part of identifying approaches to prevent rabies in cattle, a Knowledge, Attitude, and Practice (KAP) survey was conducted among cattle owners in selected rural areas of the southern rabies high-risk zone and low-risk zone in eastern Bhutan. Between March and April 2017, 562 cattle owners (281 in the east and 281 in the south) were interviewed using a questionnaire. Eighty-eight percent of the participants had heard of rabies but only 39% of the participants who had heard of rabies had adequate knowledge about rabies. Multivariable logistic regression analysis showed that residing in the south [OR = 9.25 (95% CI: 6.01-14.53)] and having seen a rabies case [OR = 2.46 (95% CI: 1.6-3.82)] were significantly associated with having adequate knowledge about rabies. Based on our scoring criteria, 65% of the total participants who had heard of rabies had a favorable attitude towards rabies control and prevention programs. The participants residing in the east were two times more likely to have a favourable attitude than their counterparts in the south [OR = 2.08 (95% CI: 1.43-3.05)]. More than 70% of the participants reported engaging in farm activities such as examining the oral cavity of sick cattle and assisting cattle during parturition. Only 25% of the participants reported using personal protective equipment while undertaking these activities. Despite a high level of rabies awareness, we observed that there is a lack of comprehensive knowledge about rabies regarding susceptible hosts, transmission routes, the health outcome of rabies infection in humans, and appropriate health-seeking behaviours. This study highlights the need to strengthen rabies education programs in rural communities to address the knowledge gaps that have been identified.

Determinants of health seeking behavior of animal bite victims in rabies endemic South Bhutan: a community-based contact-tracing survey

BACKGROUND

Dog bites are the main source of rabies infection and death in humans, contributing up to 99% of all cases. We conducted a contact-tracing study to evaluate the health seeking and treatment compliance behaviors of people following potential exposure to rabies in rabies endemic south Bhutan.

METHODS

Using information from the rabies post exposure prophylaxis (PEP) register, animal-exposed victims who had visited five hospitals in south Bhutan between January and March 2017 were traced and further data were collected from them using a structured questionnaire. A snowballing technique was used to identify victims who did not seek PEP.The survey was conducted between April and June 2017. Logistic regression was performed to assess factors associated with PEP-seeking and compliance behavior by the victims.

RESULTS

Amongst 630 who reported to hospitals, 70% (444) of people could be traced and additional 8% (39) who did not seek PEP was identified through contact tracing. Therefore, a total of 483 people were interviewed. Seventy one percent (344/483) of exposure were due to animal bites of which 80% (365/455) were considered to be provoked incidents. Common reasons for not seeking health care included assumptions that risks of infection were minor if bitten by an owned or vaccinated dog. The victims who are male (OR: 0.36; 95% CI: 0.16-0.77) and educated (OR: 0.41; 95% CI: 0.17-0.96) were less likely to seek PEP, while those that experienced unprovoked bite (OR: 5.10; 95% CI: 1.20-21.77) were more likely to seek PEP in the hospitals. Overall, 82% of the victims sought PEP from the hospitals within 24 h after exposure. Eighty three percent completed the PEP course prescribed by the physician. The respondents living in urban areas (OR: 2.67; 95% CI: 1.34-5.30) were more likely to complete the prescribed PEP course than rural dwellers.

CONCLUSIONS

There is high risk of rabies infection in southern Bhutan. It is critical to bridge knowledge gaps and dispel existing myths which will help to improve PEP seeking and compliance behavior of people exposed to rabies infection from animals. A risk-based advocacy program is necessary to prevent dog-mediated human rabies deaths.

Geographical and temporal patterns of rabies post exposure prophylaxis (PEP) incidence in humans in the Mekong River Delta and Southeast Central Coast regions in Vietnam from 2005 to 2015

BACKGROUND

In Vietnam, rabies has been a notifiable disease for more than 40 years. Over the last five years, on average, more than 350,000 people per year have been bitten by dogs and cats while more than 80 human deaths have been reported yearly. No studies have been conducted to evaluate the geographical and temporal patterns of rabies in humans in Vietnam. Therefore, the main objective of this study was to assess the geographical and temporal distributions of rabies post exposure prophylaxis (PEP) incidence in humans in Vietnam from 2005 to 2015.

METHODS

Average incidence rabies (AIR) PEP rates for every 3 or 4 years (2005-2008, 2009-2012 and 2013-2015) were calculated to describe the spatial distribution of rabies PEP. Hotspot analysis was implemented to identify patterns of spatial significance using the Getis-Ord Gi statistic. For temporal pattern analysis, two regions [Mekong River Delta (MRD) and Southeast Central Coast (SCC)], with the highest incidence rates, and the seasonal-decomposition procedure based on loess (STL), were compared to assess their temporal patterns of rabies PEP.

FINDINGS

We found hotspots in southern Vietnam and coldspots in northern Vietnam during the study period. Rabies cases were limited to specific areas. In addition, the hotspot analysis showed that new risk areas were identified in each period which were not observed in incidence rate maps. The seasonal plots showed seasonal patterns with a strong peak in February/July and a minor peak in October/December in the MRD region. However, in the SCC, a small peak was detected at the early part of each year and a strong peak in the middle of each year.

CONCLUSION

Our findings provide insight into understanding the geographical and seasonal patterns of rabies PEP in Vietnam. This study provides evidence to aid policy makers when making decisions and investing resources. Such information may also be utilized to raise public awareness to prevent rabies exposures and reduce unnecessary PEP.

Exploring animal rabies endemicity to inform control programmes in Punjab, India

Previous studies estimate that one-third of the annual global burden of rabies (~20,000 cases) occurs in India. Elimination of canine rabies is essential to reduce this burden. Surveillance of animal cases can assess both the risk to humans and the efficacy of control strategies. The objective of this study was to describe the spatial and temporal occurrence of reported confirmed cases of rabies in animals in Punjab, India, from 2004 to 2014. We analysed passive surveillance data on 556 samples submitted from 2004 to 2014 to GADVASU, Ludhiana, Punjab, India. Regression and time series analyses were conducted to understand seasonal and long-term variation of cases and identify cross-correlation of monthly cases between species. Spatio-temporal analyses assessed spatial autocorrelation of date of reporting, mean geographic centres of disease occurrence and clustering of cases using Kulldorff's space-time permutation statistic. The annual number of submissions and proportion of confirmed cases were consistent throughout 2004-2014. Most submissions (320; 57.6%) were confirmed rabies cases, including dogs (40.6%), buffalo (29.7%) and cattle (23.1%). Regression analysis of monthly cases in dogs showed seasonal variation with significant increases in cases in March and August. Monthly case numbers in buffalo decreased over time. Long-term temporal trend was not detected in dog and cattle cases. Time-series models identified significant cross-correlation between dog and buffalo cases, suggesting that buffalo cases were spillover events from dogs. Significant spatio-temporal variation or clusters of cases were not detected. These results indicate that rabies cases in animals-and therefore, the potential for exposure to humans-were temporally and spatially stable during 2004-2014 in Punjab, India. The endemic nature of rabies transmission in this region demands a coordinated, sustained control programme. This study provides baseline information for assessing the efficacy of rabies control measures and developing seasonally targeted dog vaccination and rabies awareness strategies.

Community-based survey during rabies outbreaks in Rangjung town, Trashigang, eastern Bhutan, 2016

Background

Rabies is a highly fatal disease transmitted through the bite of a rabid animal. Human deaths can be prevented by prompt administering of rabies vaccine and rabies immunoglobulin following the exposure. An assessment of community knowledge, awareness and practices on rabies is important during outbreak to understand their preparedness and target educational messages and response activities by the rapid response team.

Methods

A rabies outbreak has occurred in Rangjung town, eastern Bhutan on 4 October 2016. A rapid response team was activated to investigate outbreak and to establish a control program. A community-based questionnaire survey was conducted from 20 to 21 October 2016 to assess the community knowledge of rabies to guide outbreak preparedness and also target educational messages and response activities by the RRT.

Results

A total of 67 respondents were interviewed, of which 61% were female and 39% male. All the respondents have heard of rabies (100%), have knowledge on source of rabies (dog) and its mode of transmission in animals and humans. Most (61%) respondents were aware and also indicated that they would wash the animal bite wound with soap and water and seek medical care on the same day of exposure (100%). Majority (94%) of the respondents have indicated that they would report to the government agencies if they see any suspected rabid dogs in the community and suggested various control measures for dog population management and rabies in Rangjung including neutering procedure and mass dog vaccination. Although only few (10%) of the respondents households owned dogs and cats, but 50% of them have indicated that their dogs were allowed to roam outside the home premises posing risk of contracting rabies through rabid dog bites.

Conclusions

Although this study indicates a high level of knowledge and awareness on rabies among the community, there exists some knowledge gaps about rabies and therefore, an awareness education should be focused on the source of rabies and rabies virus transmission route to reduce public concern on nonexposure events thereby reducing the cost on unnecessary postexposure treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2393-x) contains supplementary material, which is available to authorized users.

Rabies in Costa Rica: Documentation of the Surveillance Program and the Endemic Situation from 1985 to 2014

This is the first comprehensive epidemiological analysis of rabies in Costa Rica. We characterized the occurrence of the disease and demonstrated its endemic nature in this country. In Costa Rica, as in other countries in Latin America, hematophagous vampire bats are the primary wildlife vectors transmitting the rabies virus to cattle herds. Between 1985 and 2014, a total of 78 outbreaks of bovine rabies was reported in Costa Rica, with documented cases of 723 dead cattle. Of cattle outbreaks, 82% occurred between 0 and 500 meters above sea level, and seasonality could be demonstrated on the Pacific side of the country, with significantly more outbreaks occurring during the wet season. A total of 1588 animal samples, or an average of 55 samples per year, was received by the veterinary authority (SENASA) for rabies diagnostic testing at this time. Of all samples tested, 9% (143/1588) were positive. Of these, 85.6% (125/1588) were from cattle; four dogs (0.3% [4/1588]) were diagnosed with rabies in this 30-year period. Simultaneously, an extremely low number (n = 3) of autochthonous rabies cases were reported among human patients, all of which were fatal. However, given the virus' zoonotic characteristics and predominantly fatal outcome among both cattle and humans, it is extremely important for healthcare practitioners and veterinarians to be aware of the importance of adequate wound hygiene and postexpositional rabies prophylaxis when dealing with both wild and domestic animal bites.

Comparison of mark-resight methods to estimate abundance and rabies vaccination coverage of free-roaming dogs in two urban areas of south Bhutan

In Bhutan, Capture-Neuter-Vaccinate-Release (CNVR) programs have been implemented to manage the dog population and control rabies, but no detailed evaluation has been done to assess their coverage and impact. We compared estimates of the dog population using three analytical methods: Lincoln-Petersen index, the Chapman estimate, and the logit-normal mixed effects model, and a varying number of count periods at different times of the day to recommend a protocol for applying the mark-resight framework to estimate free-roaming dog population abundance. We assessed the coverage of the CNVR program by estimating the proportion of dogs that were ear-notched and visually scored the health and skin condition of free-roaming dogs in Gelephu and Phuentsholing towns in south Bhutan, bordering India, in September-October 2012. The estimated free-roaming dog population in Gelephu using the Lincoln-Petersen index and Chapman estimates ranged from 612 to 672 and 614 to 671, respectively, while the logit-normal mixed effects model estimate based on the combined two count events was 641 (95% CI: 603-682). In Phuentsholing the Lincoln-Petersen index and Chapman estimates ranged from 525 to 583 and 524 to 582, respectively, while the logit-normal mixed effects model estimate based on the combined four count events was 555 (95% CI: 526-587). The total number of dogs counted was significantly associated with the time of day (AM versus PM; P=0.007), with a 17% improvement in dog sightings during the morning counting events. We recommend to conduct a morning marking followed by one count event the next morning and estimate population size by applying the Lincoln-Peterson corrected Chapman method or conduct two morning count events and apply the logit-normal mixed model to estimate population size. The estimated proportion of vaccinated free-roaming dogs was 56% (95% CI: 52-61%) and 58% (95% CI: 53-62%) in Gelephu and Phuentsholing, respectively. Given coverage in many neighbourhoods was below the recommended threshold of 70%, we recommend conducting an annual "mass dog vaccination only" campaign in southern Bhutan to create an immune buffer in this high rabies-risk area. The male-to-female dog ratio was 1.34:1 in Gelephu and 1.27:1 in Pheuntsholing. Population size estimates using mark-resight surveys has provided useful baseline data for understanding the population dynamics of dogs at the study sites. Mark-resight surveys provide useful information for designing and managing the logistics of dog vaccination or CNVR programs, assessing vaccination coverage, and for evaluating the impact of neutering programs on the size and structure of dog populations over time.

Community-based study on knowledge, attitudes and perception of rabies in Gelephu, south-central Bhutan

Community knowledge, attitudes and practices are important both for prevention of human deaths due to rabies and for control of the disease in animals. This study was a cross-sectional survey investigating the level of community knowledge as well as attitudes and perceptions about rabies in Gelephu, south-central Bhutan, a region endemic for rabies. A total of 615 household respondents were interviewed, of which 224 (36%) were male and 391 (64%) were female. The majority of respondents had a high level of knowledge, attitudes and perception of rabies and had a positive attitude towards the prevention and control of rabies. Multivariate logistic regression modelling showed that better knowledge of rabies was predicted by gender, educational level and dog ownership status of respondents, whilst health-seeking behaviour of animal bite injuries was predicted by dog ownership status, presence of children in the household and occupation of the respondents. The majority of respondents believed that stray dogs are a problem in the community and felt that it was important to control the dog population in Gelephu. These findings also indicate that there exists a knowledge gap about rabies in the community that could be improved by creating an awareness education programme.

Review of rabies epidemiology and control in South, South East and East Asia: past, present and prospects for elimination

Rabies is a serious public health problem in Asia. It causes substantial animal welfare, economic and human health impacts, with approximately 39,000 human deaths each year. Domestic dogs are the main reservoir and source of rabies in Asia. Common constraints for the control of rabies in the countries of Asia include inadequate resources; lack of political commitment to control programs; lack of consensus on strategy; weak intersectoral coordination and inadequate management structure; insensitive surveillance systems; limited accessibility to modern rabies vaccine and supply problems; lack of public awareness and public cooperation; and the existence of myths and religious issues. In this review, we summarize the epidemiology of rabies in both human and animals in each South and South East Asian country, the past and current approaches to control and the prospect for rabies elimination. We conclude that defining the cost of rabies to society and communicating this to decisionmakers might be the key to achieving such an advance.

Anthropogenic and environmental risk factors for rabies occurrence in Bhutan

Anthropogenic and environmental factors were assessed as predictors of sub-districts in Bhutan that reported rabies in domestic animals during the period 1996-2009. Rabies surveillance data were retrieved from the Veterinary Information System database. Anthropogenic and environmental information were obtained from public data sources. Using the total number of rabies cases reported in domestic animals, the 205 sub-districts of Bhutan were categorized as those sub-districts that reported rabies and those that did not report rabies (n=146). Logistic regression models were fit to the data and odds ratios and 95% confidence intervals were estimated. Sub-districts that share a border with India (OR 10.43; 95% CI: 4.42-24.64; P<0.001); sub-districts connected by major roads (OR 3.09; 95% CI: 1.24-7.68; P=0.015); and greater human population density (OR 3.26; 95% CI: 1.48-7.21, P=0.003) were significantly associated with a sub-district reporting animal rabies in Bhutan during 1996-2009. Results suggest that human population characteristics play an important role in rabies occurrence.

Human and animal rabies prevention and control cost in Bhutan, 2001-2008: the cost-benefit of dog rabies elimination

The objective of this study was to estimate the cost of various interventions and to quantify the economic impacts of rabies in Bhutan. Cost-benefit of dog rabies elimination versus human post exposure treatment cost was also assessed. The average direct medical cost of human post-exposure treatment (using rabies vaccine only) was estimated to be Nu. 1615 (US$ 35.65) per 5-dose Essen regimen per patient. The cost would increase to Nu. 2497 (US$ 55.13) and Nu. 19,633 (US$ 433.41) per patient when one dose of either equine rabies immunoglobulin (ERIG) or human rabies immunoglobulin (HRIG) is administered, respectively. The societal cost (direct medical and indirect patient expenses) per patient was estimated to be Nu. 2019 (US$ 45), Nu. 2901 (US$ 64) and Nu. 20,037 (US$ 442) using vaccine only, vaccine with ERIG and vaccine with HRIG, respectively. The average cost per dog vaccination and sterilization were estimated to be Nu. 75 (US$ 1.66) and Nu. 288 (US$ 6.36), respectively. The total direct cost of rabies and various interventions between 2001 and 2008 was estimated to be Nu. 46.95 million (US$ 1.03 million). The direct cost for intensified human PET was estimated to be Nu. 5.85 million (US$ 0.11 million) per year with a cumulated estimated costs of Nu. 35.10 million (US$ 0.70 million) while the cost of mass dog vaccination with at least 70% coverage is estimated to be approximately Nu. 10.31 million (US$ 0.21 million) at the end of 6 years. The combined cost of mass dog vaccination and human PET was estimated to be greater than the cost of human PET alone during the first 2 years of the campaign, and then would be lower than human PET cost alone after the 5th year of the campaign. The total cumulated cost of the combined strategy was estimated to be Nu. 34.14 million (US$ 0.73 million) and would be lower than the cumulated cost of human PET alone (Nu. 35.10 million, US$ 0.77 million) at the end of 6 years. Rabies represents a substantial economic impact to the Bhutanese society. Well-planned and implemented mass dog vaccination would result in elimination of rabies reservoirs in the domestic dog population and would eliminate human rabies cases. It would also reduce the recurrent expenditure on human post-exposure treatment.

Dog bites in humans and estimating human rabies mortality in rabies endemic areas of Bhutan

BACKGROUND

Dog bites in humans are a public health problem worldwide. The issues of increasing stray dog populations, rabies outbreaks, and the risk of dogs biting humans have been frequently reported by the media in Bhutan. This study aimed to estimate the bite incidence and identify the risk factors for dog bites in humans, and to estimate human deaths from rabies in rabies endemic south Bhutan.

METHODS

A hospital-based questionnaire survey was conducted during 2009-2010 among dog bites victims who visited three hospitals in Bhutan for anti-rabies vaccine injection. Decision tree modeling was used to estimate human deaths from rabies following dog bite injuries in two rabies endemic areas of south Bhutan.

RESULTS

Three hundred and twenty four dog bite victims were interviewed. The annual incidence of dog bites differed between the hospital catchment areas: 869.8 (95% CI: 722.8-1022.5), 293.8 (240-358.2) and 284.8 (251.2-323) per 100,000 people in Gelephu, Phuentsholing and Thimphu, respectively. Males (62%) were more at risk than females (P<0.001). Children aged 5-9 years were bitten more than other age groups. The majority of victims (71%) were bitten by stray dogs. No direct fatal injury was reported. In two hospital areas (Gelephu and Phuentsholing) in south Bhutan the annual incidence of death from rabies was 3.14 (95% CI: 1.57-6.29) per 100,000 population. The decision tree model predicted an equivalent annual incidence of 4.67 (95% CI: 2.53-7.53) deaths/100,000 population at risk. In the absence of post exposure prophylaxis, the model predicted 19.24 (95% CI: 13.69-25.14) deaths/year in these two areas.

CONCLUSIONS

Increased educational awareness of people about the risk of dog bites and rabies is necessary, particularly for children in rabies endemic areas of Bhutan.

Human rabies post exposure prophylaxis in Bhutan, 2005-2008: trends and risk factors

The aim of this study was to understand the use and distribution of human rabies post exposure prophylaxis (PEP) vaccine in Bhutan and to identify risk factors for receiving an incomplete course of the vaccine. We analyzed post exposure treatment records from 28 medical hospitals from 2005 to 2008. Males (59%) accounted for significantly more PEP events than females (41%) across all age groups (P<0.001). Children - particularly 5-9 years of age - received more rabies PEP than other age groups. Animal bite and non-bite accounted for 27% (n=2239) and 16% (n=1303) of rabies PEP, respectively, whilst 57% (n=4773) of the PEP events had no recorded information about the reasons for post exposure treatment. Post exposure treatment was provided throughout the year with a higher number during the winter and spring months. The number of PEP events significantly (P<0.001) increased between 2005 and 2008, from <1000 to >2800 events, respectively. Significantly (P<0.001) more PEP events were reported from the southern parts of Bhutan that are endemic for rabies or those areas in eastern Bhutan that have reported rabies outbreaks than other parts of Bhutan. Forty percent (n=3360) of the patients received an incomplete course of vaccine (<5-doses of vaccine intramuscular). Results suggest that patients with animal bite injury were less likely to receive an incomplete vaccine course than non-bite recipients, and patients presented to hospitals in rabies endemic or outbreak areas were less likely to receive an incomplete course than in non-rabies areas or rabies free areas. Similarly, patients presenting to hospitals for PEP during spring and summers months were less likely to receive an incomplete vaccine course than those during other seasons. Public education campaigns need to be conducted in Bhutan to reduce dog bite incidents and also to prevent mass exposures to rabies. A thorough assessment of each individual case based on the WHO guidelines would reduce unnecessary PEP (and therefore costs) in Bhutan.