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

Rabies in rural northeast India: A case report emphasising the urgency of the One Health approach

Dog-mediated rabies is endemic in India. The country records the highest mortality due to dog-bite-related rabies despite the availability of interventions to prevent deaths. We present a case study of the death of a 59-year-old man in a suburban town of Northeast India after a dog bite from an owned pup. Through this case study, we investigate various omissions and commissions in communities and health professionals that make rabies rampant in India. The circumstances surrounding the death were investigated by interviewing the wife, relatives, neighbour, the hospital/nursing home where the bite case was reported, the district Rapid Response Team (RRT), and the Veterinary and Animal Health Department Officer and through the information recorded in the disease outbreak report. While the biting animal was not vaccinated and had no restriction over its movement imposed by the owners, the response of the hospital staff and public authorities was delayed and inadequate. A poignant reminder of the complexities surrounding dog-mediated rabies in India, this case study calls for a holistic protocol to address dog bites through ensuring the One Health approach encompassing education, provision of post-exposure prophylaxis (PEP) and canine rabies vaccines for dogs, promotion of responsible dog ownership, and intersectoral collaboration. Moreover, strengthening communication channels through effective data exchange and encouraging synergy among healthcare, veterinary, and public health sectors is indispensable to maximize the impact of rabies prevention and control interventions.

Epidemiological Profile and Awareness Regarding Animal Bite Management in an Urban Area

OBJECTIVES

The most common way for people to contract the deadly zoonotic disease rabies is through animal bites. This study was designed because there is a shortage of community-based data to determine the true extent of rabies infection and a lack of understanding regarding patient misconceptions in urban areas. The objective was to determine the scope of the issue and the epidemiological features of animal bite incidents.

METHODOLOGY

This was a facility-based cross-sectional study conducted at the field practice area (Urban Health Training Centre) under the Department of Community Medicine, Government Medical College. The study duration was one year (May 2023 to April 2024). Consecutive patients (accompanied by an attendant) attending the Urban Health Training Centre were included in the study. A purposive sampling technique was used, and around 400 animal bite cases were recorded in one year at the Urban Health Training Centre.

RESULTS

Out of 1503 male cases at the Urban Health Training Centre, around 255 were dog bite cases (50.6%), whereas out of 1302 females visiting the Urban Health Training Centre, around 145 were dog bite cases (48%). The majority (35%) belonged to the age group of 11 to 20 years for both males and females. The mean age of the cases was 19.4 ± 3.4 years. The study found a male preponderance (64%), with females constituting 36%. The right lower limb (49.5%), left lower limb (39%), and upper limb were the most frequently bitten sites. Fifty-one percent of the cases fell into Category II. According to local data, the most popular home management practices were ghee oil and cold treatments. Although Category III is the most severe bite, only 35% had taken the anti-rabies vaccine (ARV), and 8.75% had received rabies immunoglobulin.

CONCLUSION

The public and medical community need to be made aware of the importance of wound care and the prudent use of the anti-rabies vaccine.

Rabies control in Bangladesh and prediction of human rabies cases by 2030: a One Health approach

Background

Bangladesh is making progress toward achieving zero dog-mediated rabies deaths by 2030, a global goal set in 2015.

Methods

Drawing from multiple datasets, including patient immunisation record books and mass dog vaccination (MDV) databases, we conducted a comprehensive analysis between 2011 and 2023 to understand the effectiveness of rabies control programmes and predict human rabies cases in Bangladesh by 2030 using time-series forecasting models. We also compared rabies virus sequences from GenBank in Bangladesh and other South Asian countries.

Findings

The estimated dog population in Bangladesh was determined to be 1,668,140, with an average dog population density of 12.83 dogs/km2 (95% CI 11.14-14.53) and a human-to-dog ratio of 86.70 (95% CI 76.60-96.80). The MDV campaign has led to the vaccination of an average of 21,295 dogs (95% CI 18,654-23,935) per district annually out of an estimated 26,065 dogs (95% CI 22,898-29,230). A declining trend in predicted and observed human rabies cases has been identified, suggesting that Bangladesh is poised to make substantial progress towards achieving the 'Zero by 30' goal, provided the current trajectory continues. The phylogenetic analysis shows that rabies viruses in Bangladesh belong to the Arctic-like-1 group, which differs from those in Bhutan despite sharing a common ancestor.

Interpretation

Bangladesh's One Health approach demonstrated that an increase in MDV and anti-rabies vaccine (ARV) resulted in a decline in the relative risk of human rabies cases, indicating that eliminating dog-mediated human rabies could be achievable.

Funding

The study was supported by the Communicable Disease Control (CDC) Division of the Directorate General of Health Services (DGHS) of the People's Republic of Bangladesh.

Trends in Animal Bites and Rabies-related Deaths in Northern Iran: Implications for Public Health Interventions

BACKGROUND

Rabies remains a public health problem in middle-income countries like Iran, despite being preventable. This study aimed to evaluate the six-year incidence of animal bites in the southern Caspian Sea region from 2016 to 2022, and focus on estimating the direct costs of animal bite cases using the incidence-based method.

METHODS

A multicenter, registry-based study was conducted using surveillance data of animal bites.

RESULTS

Of the 40922 cases reported during the study period, 65.9% were male and 34.1% were female. Animal bites were most frequent among individuals over 50 years of age (23.5%), while children under 10 years of age had the lowest frequency of animal bites (2.3%). Animal bites were most common in June. Dogs were responsible for 33277 (81%) cases, cats for 5,624 (13.7%) cases, cows for 1054 (2.5%) cases, and other animals for the remaining cases. During the six-year study period, four deaths due to rabies were reported in the study area. The annual bite incidence rate was 386.3 per 100000 people in northern Iran. The males-to-female ratio was highest in 2019 (M/F ratio=2.4, 95% CI=1.2‒3.4).

CONCLUSION

The elderly are at higher risk of animal bites, especially in rural areas. It is important to emphasize the use of protective clothing, washing wounds with soap water and rabies vaccination as initial treatment. Targeted vaccination efforts for eligible animals should be prioritized to minimize unnecessary financial burden. Educating farmers about rabies prevention programs, especially in cases of cow bites, is also important.

A review of human dog-bite injuries in Kitui South subcounty, Kenya (2017-2021)

Introduction

Dog bites continue to be a serious public health issue due to their association with the transmission of rabies virus. In Kenya, there are no studies estimating dog-bite incidence. Annual mortalities resulting from dog-mediated rabies are estimated at 523 (95% confidence interval 134-1100). The main objective of this study was to assess major risk factors associated with dog bites in Kitui South subcounty, Kenya, between 2017 and 2021.

Methods

We recruited 387 dog-bite patients (cases) and 387 non-bite patients (controls) for the case-control study from the Mutomo Mission Hospital and the Ikutha Level 4 Hospital records. Multivariable logistic regression analysis evaluated the association between risk factors and dog-bite cases. In the final model, pairwise interactions among variables were evaluated. The model fit was evaluated using receiver operating characteristics and area under the curve.

Results

The study found that the dog-bite incidence was highest in Kanziko ward in Kitui South subcounty. Fifty-one percent (108 bites) of dog-bite victims were children under 15 years of age, with 53% (N = 68) being men and 36% (N = 77) being bitten on the limbs. Dog bites mostly (44%, N = 93) occurred between October and December (short rainy season). Age group and season were identified as the most significant variables for high dog-bite incidence in Kitui South subcounty.

Conclusions

Promotion of responsible dog ownership and reinforcement of dog control policies may prove more effective in reducing dog-bite injuries in Kitui South subcounty.

Epidemiological pattern and management of dog bite injuries in Karachi, Pakistan: A cross-sectional study

BACKGROUND

Dog bite injuries are a common problem globally; however, little is known about the epidemiology of dog bite injury from a low-and-middle-income country like Pakistan. This study aims to determine the epidemiology of dog bite injuries among children and adults from a tertiary care hospital in Karachi, Pakistan.

METHODS

We conducted a cross-sectional study on dog bite patients visiting the emergency department from November 2015 to August 2016 of a major public tertiary care hospital. Data was collected using a structured questionnaire on demographic details, bite history, and management of dog bite victims. Descriptive analysis was reported. Chi-square test was applied to check the associations between age-specific dog bite cases and independent variables.

RESULTS

2178 participants were included in the analysis. 715 (38.8%) were children less than 18 years old, and 1463 (61.2%) were adults over 18 years. A majority of the patients were males (1909, 87.7%). Results show that most dog bite injuries (2052, 94.2%) tend to occur outside the house by stray dogs biting without provocation. People aged 18 years and above (61.2%) and males (children: 84.6%, adults: 89.1%) tend to be bitten more often. Lower limbs are most frequently bitten (children: 69.5%, adults: 85.8%). Free-roaming stray dogs (children: 73.4%, adults: 74.9%) were involved in reported biting cases. Many of the patients did not receive appropriate first aid and instead just washed the wound with soap and water (children: 45.1%, adults: 43.7%). 99% of the victims received Tetanus toxoid, Rabies vaccine, and immunoglobulins while in the emergency department.

CONCLUSION

There is a high burden of dog bite injuries from stray dogs in Karachi, Pakistan. Efforts should be made to create awareness among the general public on the risks of dog bites and on seeking appropriate first aid and medical attention for a dog bite injury.

Analysis of dog bite surveillance data, Volta Region, Ghana, 2020

Introduction

Dog bite is the second most common injury sustained by humans after snake bites, and it is amongst the top 12 causes of non-fatal injuries worldwide. Globally, 59,000 human deaths occur annually due to rabies, and 95% of these deaths occur in Asia and Africa. Dog bites remained a public health concern in Ghana, with three out of every 1000 incidence resulting in human rabies. Analysis of the surveillance data is key in understanding the burden of dog bites in the Volta region. This study describes the epidemiology of dog bites in the Volta Region, Ghana, to inform policy on prevention and control.

Methods

We conducted a descriptive analysis of secondary data on dog bites. We obtained aggregate data from 2015 to 2019 from the District Health Management Information System (DHMIS). Variables extracted were gender, age, and location. Data were entered into a Microsoft Excel cleaned, reviewed, and analyzed. We used descriptive statistics to summarize results into frequency and proportion and displayed results in tables, graphs, and maps.

Results

During the study period, 4737 dog bite cases were identified from a population of 1,907,529 (incidence of 248 per 100,000). Twelve (0.25%) humans were confirmed for rabies with a 100% case fatality rate. Males accounted for 2455 (51.8%) of dog bite cases. The age group between 10 and 19 years (21.9%) was most affected. About 35.0% (1640/4737) were administered with the anti-rabies vaccine, and 25.3% (1200/4737) were administered anti-tetanus toxoid. Keta district (550 per 100000) reported the highest incidence of dog bites. Dog bite cases were highest in the third and fourth quarters of 2016 and the first quarter of 2017.

Conclusion

The incidence of dog bites and rabies was high in the Volta region. Children and adolescents were mostly affected. There was a low coverage rate of anti-rabies vaccine and anti-tetanus toxoids usage. We recommended that the Regional Health Directorates and the Regional Veterinary Department develop robust strategies to control stray or free-roaming dogs in the Volta region.

An exploratory study on the perceptions of rabies and ill-health causations and health seeking behaviours of school children and local communities in southern Bhutan

BACKGROUND

The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan.

METHODS

We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data.

RESULTS

The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments.

CONCLUSION

There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with "One Health" public health sectors.

Soares Magalhães R, Weese JS, Ahmed NO, Rupprecht CE, Clark NJ. Modelling modifiable factors associated with the probability of human rabies deaths among self-reported victims of dog bites in Abuja, Nigeria

Canine-mediated rabies kills tens of thousands of people annually in lesser-developed communities of Asia, Africa, and the Americas, primarily through bites from infected dogs. Multiple rabies outbreaks have been associated with human deaths in Nigeria. However, the lack of quality data on human rabies hinders advocacy and resource allocation for effective prevention and control. We obtained 20 years of dog bite surveillance data across 19 major hospitals in Abuja, incorporating modifiable and environmental covariates. To overcome the challenge of missing information, we used a Bayesian approach with expert-solicited prior information to jointly model missing covariate data and the additive effects of the covariates on the predicted probability of human death after rabies virus exposure. Only 1155 cases of dog bites were recorded throughout the study period, out of which 4.2% (N = 49) died of rabies. The odds for risk of human death were predicted to decrease among individuals who were bitten by owned dogs compared to those bitten by free-roaming dogs. Similarly, there was a predicted decrease in the probability of human death among victims bitten by vaccinated dogs compared to those bitten by unvaccinated dogs. The odds for the risk of human death after bitten individuals received rabies prophylaxis were predicted to decrease compared to no prophylaxis. We demonstrate the practical application of a regularised Bayesian approach to model sparse dog bite surveillance data to uncover risk factors for human rabies, with broader applications in other endemic rabies settings with similar profiles. The low reporting observed in this study underscores the need for community engagement and investment in surveillance to increase data availability. Better data on bite cases will help to estimate the burden of rabies in Nigeria and would be important to plan effective prevention and control of this disease.

Are children and dogs best friends? A scoping review to explore the positive and negative effects of child-dog interactions

Personal wellbeing is greatly influenced by our childhood and adolescence, and the relationships formed during those phases of our development. The human-dog bond represents a significant relationship that started thousands of years ago. There is a higher prevalence of dog ownership around the world, especially in households including children. This has resulted in a growing number of researchers studying our interactions with dogs and an expanding evidence base from the exploration of child-dog interactions. We review the potential effects of child-dog interactions on the physical, mental, and social wellbeing of both species. A search of the SCOPUS database identified documents published between January 1980 and April 2022. Filtering for key inclusion criteria, duplicate removals, and inspecting the references of these documents for additional sources, we reviewed a total of 393 documents, 88% of which were scientific articles. We were able to define the numerous ways in which children and dogs interact, be it neutral (e.g., sharing a common area), positive (e.g., petting), or negative (e.g., biting). Then, we found evidence for an association between childhood interaction with dogs and an array of benefits such as increased physical activities, a reduction of stress, and the development of empathy. Nonetheless, several detrimental outcomes have also been identified for both humans and dogs. Children are the most at-risk population regarding dog bites and dog-borne zoonoses, which may lead to injuries/illness, a subsequent fear of dogs, or even death. Moreover, pet bereavement is generally inevitable when living with a canine companion and should not be trivialized. With a canine focus, children sometimes take part in caretaking behaviors toward them, such as feeding or going for walks. These represent opportunities for dogs to relieve themselves outside, but also to exercise and socialize. By contrast, a lack of physical activity can lead to the onset of obesity in both dogs and children. Dogs may present greater levels of stress when in the presence of children. Finally, the welfare of assistance, therapy, and free-roaming dogs who may interact with children remains underexplored. Overall, it appears that the benefits of child-dog interactions outweigh the risks for children but not for dogs; determination of the effects on both species, positive as well as negative, still requires further development. We call for longitudinal studies and cross-cultural research in the future to better understand the impact of child-dog interactions. Our review is important for people in and outside of the scientific community, to pediatricians, veterinarians, and current or future dog owners seeking to extend their knowledge, and to inform future research of scientists studying dogs and human-animal interactions.

Assessment of the rabies education among middle secondary school students of southeastern Bhutan

Rabies is one of the most important zoonotic diseases that mostly affect children. We conducted a rabies education among 129 secondary school children (intervention group = 94 students, control group = 35 students) in two schools in southeast Bhutan and evaluated the effectiveness of the lesson by comparing the knowledge, perception and safety behaviour score about rabies before and after education. We also assessed the knowledge retention capacity of the students at three months post intervention. Our findings indicated that short rabies lesson significantly (P<0.001) improved the mean knowledge score from 19.98(±2.72) to 26.96(±2.24) in the intervention group. Similarly, mean scores for perception and safety behaviour improved significantly (P<0.001) from 10.77 (±1.89) to 13.95 (±1.36) and 9.809 (±1.85) to 12.97 (±1.54), respectively. Although the scores have reduced significantly (P<0.001) at three months post intervention, most of the rabies information was largely retained by the students. In control group, significant increase in mean scores were also observed for perception from 10.17 (±2.38) to 11.2 (±2.44) and safety behaviour from 9.14(±1.44) to 10.74 (±1.95) after 3 months of education. The finding demonstrate that a short rabies lesson is effective in improving knowledge, perceptions and understanding of dog bites safety behaviour among the school children. However, there is a need for a frequent awareness program, at least quarterly or half yearly. Rabies education should focus on critical points such as dog bites being the main source of rabies and the importance washing a dog/animal bite wound with soap and water, and visiting the hospital for medical advice following animal bites.

Owned dog population size and ownership patterns in Costa Rica

Dogs (Canis lupus familiaris) are one of the most common pets around the world but ownership patterns and human-dog interactions have been changing, particularly in developing nations. We conducted household surveys in Costa Rica to characterize dog ownership, the owned dog population, where dogs were confined at night and in the morning, and behaviors regarding selected dog care issues. We also compared these results to similar questionnaires used in Costa Rica over the past 20 years. We found 76% of households in Costa Rica owned at least one dog and on average there were about 1.4 dogs owned per household. These dog ownership rates are higher than previous estimates. The probability of owning a dog was highest on farms and lowest in single family dwellings without a yard, higher among respondents that owned their homes and decreasing with increasing human population density The total number of owned dogs in Costa Rica was estimated to be 2,222,032 (95% confidence intervals: 1,981,497-2,503,751). The sterilization rate for homed dogs in 2020 was approximately 62% (females: 67%, males: 61%) which is higher than the 18% of owned dogs that were sterilized in a 2003 survey. Overall, only 1.2% (95% CI: 0.3-2.5%) of owned dogs slept on the street with a slightly higher proportion on the street at 8 am. The number of owned dogs roaming the streets at night nation-wide was estimated to be 27,208 (95% CI: 7,557-56,619) compared to 43,142 (95% CI: 20,118-73,618) on the street at 8 am. The number of unowned free-roaming dogs in Costa Rica has never been estimated but we can generate some idea of the size of the unowned dog population by determining the proportion of free-roaming dogs on the street wearing collars. There was a negative relationship between human population density and owned dogs being on the street meaning fewer dogs roam the streets in highly populated areas compared to less populated areas. Overall, we identify trends against which future progress can be measured and provide information that are critical in designing effective humane dog management programs in Costa Rica in the future.

Prophylactic treatment abandonment in people bitten by suspected rabid animals, El Salvador, 2013-2017

Introduction

Around the world 60,000 people die from rabies each year. The main form of exposure to rabies is by the bite of animals infected with the virus. More than 20,000 cases of rabies-transmitting animal bites are reported each year, in El Salvador, a country located in Central America. People exposed should be managed with rabies prophylaxis.

Objective

To determine the abandonment of post-exposure prophylaxis (PEP) cumulative incidence (CI) in humans bitten by suspected rabid animals in El Salvador from 2013 to 2017.

Methodology

This is an ecological study based on the cases of bites by suspected rabid animals reported between 2013 and 2017 in the public health system of El Salvador. Descriptive and correlation analysis was performed using Statistical Package for the Social Sciences (SPSS) version 24. The municipality CI, expressed per 100,000 inhabitants.

Results

The national CI of abandonment PEP in humans bitten by suspected rabid animals was 25.6 × 100,000 inhabitants. Simple bivariate correlation analysis shows that the departments with the highest CI of bites caused by cats, wild animals, and bites on the neck (R ² = 0.99 P < 0.05) are mostly associated with dropping out of the PEP.

Conclusion

In El Salvador, the abandonment CI of PEP is lower than other countries, however, bites by rabid suspected animal are frequent, this represents a public health problem due to the presence of the rabies virus in wild animals and the high lethality of the disease. Municipalities where head bites are common are the most related to the abandonment of PEP.

Knowledge, Attitude and Practices of rabies during an outbreak in Samtse Municipality, Bhutan: A cross-sectional study

Background

A rabies outbreak in dogs occurred on February 22, 2021, in the Samtse Municipality, Bhutan. A rapid response team (RRT) was activated comprising of human and animal health teams to investigate and contain this outbreak. An assessment of the knowledge, attitude, and practice (KAP) on rabies was elicited during this period to develop evidence-based education material.

Methods

A face-to-face KAP questionnaire was administered to a volunteer member of 55 households in two communities (Norbuling and Xing Workshop areas) following the rabies outbreak in the Samtse Municipality from March 15 to 22, 2021. Descriptive statistics were used to describe the demographic characteristics. The associations between the KAP scores were assessed using the Pearson correlation coefficient.

Results

Of the 55 respondents, 63.6% (35) had poor knowledge, 90.9% (50) and 63.6% (35) reported good attitude and practice toward rabies. Three (5.5%) participants had not heard about rabies. The other misconceptions were that rabies can be prevented with antibiotics (67.3%, 37), dressing the bite wounds (20.0%, 11), and seeking treatment from the local healer (5.5%, 3). Correct knowledge was reported on excessive salivation as the sign of the rabid animal (58.2% 32), rabies prevention through vaccination (81.8%, 45), and seeking medical care on the same day (94.5%, 52). Eighty-nine percent (49) vaccinated their dogs and domestic animals annually, 100% received post-exposure prophylaxis (PEP) after an animal bite, 78.2% (43) washed the animal bite wounds with soap and water, and 9.1% (5) would consult the local healer for animal bites. A majority (78.2%, 43) of them agreed that rabies is a serious public health problem in the Samtse Municipality and 49.1% (27) agreed that the public was adequately informed about rabies. A positive correlation was observed between the knowledge-practice scores (r = 0.3983, P value = 0.0026), and attitude-practice scores (r = 0.4684, P value < 0.001).

Conclusion

The poor knowledge of rabies in this study needs to be addressed urgently. The main misconceptions included were that rabies is not fatal, dressing animal bite wounds, and seeking dog and animal bite care from local healers. Health education should focus on these misconceptions.

Determinants of Rabies Post-exposure Prophylaxis Drop-Out in the Region of San-Pedro, Côte d'Ivoire

Abstract

Despite the fact that death from rabies is 100% preventable with a course of post-exposure prophylaxis (PEP) treatment, canine rabies still causes about 59,000 human deaths worldwide annually, half of which are occurring in Africa. In Côte d'Ivoire, rabies remains a threat partly due to the high drop-out rate of the life-saving human PEP treatment among people exposed to dog bites. Each year, half of the victims starting treatment, do not complete the course. The current study therefore assessed the determinants for drop-out of the life-saving treatment among people exposed to rabies in the department of San-Pedro in Côte d'Ivoire.

Methods

A mixed-methods approach was used, including questionnaires, observation, individual interviews and focus group discussions, to gather socio-demographic and economic data from 235 participants about possible reasons for abandoning treatment. The study population consisted of patients and medical and veterinary health professionals who were selected using stratified sampling and purposive selection from a database available at the Rabies Center of San Pedro.

Result

The drop-out of PEP treatment was related to perception bias and a habit of low attendance of health care and vaccination centers in the population. Quantitative analysis shows differences between rural and urban areas and an association with age when it comes to treatment completion. The dropout rate was most significant among patients who, in case of other illness, did not routinely see a doctor or go to vaccination centers. The rate of abandonment was higher among those who believed that dog-related injuries could be easily treated at home, and who believed that a person with rabies could be cured without completing the preventive treatment. Insufficient provision of health information on rabies and logistic constraints related to the practical organization of treatment, including the long distance to the anti-rabies center and weaknesses in the patient follow-up procedure, did not contribute to the completion of PEP.

Conclusion

Established determinants for drop-out provide a framework for effective design and implementation of rabies control strategies to accelerate rabies deaths elimination efforts. In particular, access to PEP and community knowledge about rabies need to be improved and integrated in the health system and education system, respectively.

Epidemiology of rabies immune globulin use in paediatric and adult patients in the USA: a cross-sectional prevalence study

OBJECTIVES

To compare the epidemiology of paediatric and adult patients receiving rabies immune globulin (RIG).

DESIGN

Cross-sectional prevalence study.

SETTING

Eligible participants from the Symphony Integrated Dataverse presenting between 2013 and 2019.

PARTICIPANTS

All adult and paediatric patients with integrated claims and demographic data associated with RIG use from the Symphony Integrated Dataverse from 2013 to 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence of diagnoses and procedures associated with paediatric and adult patient population based on frequency of International Classification of Diseases (ICD-9/ICD-10) and Current Procedural Terminology codes, respectively.

METHODS

We used mutual information to identify features that differentiate the paediatric from adult patient population. Prevalence ratios were calculated to compare adult and paediatric patients.

RESULTS

There were 79 766 adult and 20 381 paediatric patients who met the inclusion criteria. Paediatric patients had a 5.92-fold higher prevalence of 'open wounds to the head; neck; and trunk', 3.10-fold higher prevalence of 'abrasion or friction burn of face; neck; and scalp except eye; without mention of infection', 4.44-fold higher prevalence of 'open wound of scalp; without mention of complication' and 6.75-fold higher prevalence of 'laceration of skin of eyelid and periocular area | laceration of eyelid involving lacrimal passages'. Paediatric patients had a 3.83-fold higher prevalence of complex repairs compared with adult patients (n=157, 0.7% vs n=157, 0.2%, respectively).

CONCLUSIONS

Paediatric patients represent a significant proportion of the patient population receiving RIG, and are associated with higher prevalence of codes reporting repair of larger, more complex wounds in highly innervated anatomical regions. Dosing and administration of RIG must be informed by animal bite wound characteristics; clinicians should understand the differences between presentations in adults and children and treat accordingly.

Stray Dogs and Public Health: Population Estimation in Punjab, India

The overpopulation of stray dogs is a serious public health and animal welfare concern in India. Neglected zoonotic diseases such as rabies and echinococcosis are transmitted at the stray–dog human interface, particularly in low to middle-income countries. The current study was designed to estimate the stray dog populations in Punjab to enhance the implementation of animal birth and disease (for example, rabies vaccination) control programs. This is the first systematic estimation of the stray dog population using a recommended method (mark–re-sight) in Punjab, India. The study was conducted from August 2016 to November 2017 in selected villages or wards in Punjab. For the rural areas, 22 sub-districts in each district were randomly selected, then one village from each of the 22 selected sub-districts was selected (by convenience sampling). For urban areas, 3 towns (less than 100,000 human population) and 2 large cities (more than or equal to 100,000 human population) were randomly selected, followed by convenience selection of two wards from each of the 5 selected towns/cities. To estimate the dog population size, we used a modified mark–re-sight procedure and analysed counts using two methods; the Lincoln–Petersen formula with Chapman’s correction, and an application of Good–Turing theory (SuperDuplicates method; estimated per km2 and per 1000 adult humans and were compared between localities (villages vs. towns), dog sex (male vs. female) and age group (young vs. adult) using linear mixed models with district as a random effect. The predicted mean (95% CI) count of the dogs per village or ward were extrapolated to estimate the number of stray dogs in Punjab based on (a) the number of villages and wards in the state; (b) the adult human population of the state and (c) the built-up area of the state. Median stray dog populations per village and per ward using the Lincoln–Petersen formula with Chapman’s correction were estimated to be 33 and 65 dogs, respectively. Higher estimates of 61 per village and 112 per ward are reported using the SuperDuplicates method. The number of males was significantly higher than the number of females and the number of adult dogs was about three times the number of young dogs. Based on different methods, estimates of the mean stray dog population in the state of Punjab ranged from 519,000 to 1,569,000. The current study revealed that there are a substantial number of stray dogs and a high number reside in rural (versus urban) areas in Punjab. The estimated stray dog numbers pose a potential public health hazard in Punjab. This impact requires assessment. The estimated stray dog numbers will help develop a dog population and rabies control program in which information about the logistics required as well as costs of implementing such programmes in Punjab can be incorporated.

Rabies burden in Côte d'Ivoire

BACKGROUND

In Côte d'Ivoire, just as in the majority of developing countries, rabies cases are underestimated. The official data are based on passive surveillance studies which cannot provide true estimates. Therefore, the economic and health burden of rabies is underestimated. To be able to better estimate the true burden of rabies, this study looked at surveillance data of bite records and household survey.

METHODOLOGY

The data was collected from a cross-sectional survey of 8004 households, of which 4002 were in the Department of Bouaké and 4002 in the Department of San Pedro. Further data was collected from Human Rabies control centres and from the respective veterinary services. We estimate the burden of rabies through data from the bites surveillance records. Human deaths from rabies were estimated using a series of probability steps to determine the likelihood of clinical rabies in a person after being bitten by a suspected rabid dog. Monte Carlo simulations of a series of interconnected probabilities were used to estimate the rabies burden in the country.

RESULTS

The number of deaths from rabies was estimated at 637deaths per year [95% CI 442-849] and human mortality from rabies was estimated at 2.61 per 100'000 [95% CI 1.81-3.56], which represents 24-47 times more cases than the official data. Deaths due to rabies are responsible for 23,252 Disability Adjusted Life Years (DALY) lost each year [95% CI 16,122-30,969]. The estimated annual cost of rabies is 40.15 million USD [95% CI 27.8-53.4]. Overall, 99% of the cost was due to premature deaths. The cost of post-exposure prophylaxis was estimated at 1.6 million USD and represented 1% of the overall cost of rabies.

CONCLUSION

This study highlights the underreporting of rabies cases by the official health information system in Côte d'Ivoire and the annual financial losses related to rabies are equivalent to the estimated cost of the elimination of rabies by 2030. Thus, investing in the fight against in Côte d'Ivoire will be cost effective.

The wound severity of animal bite victims visiting rabies prevention clinics and the influencing factors in Central China: a cross-sectional investigation

Background

Animal bites are a major public health problem. The more serious the bite wound is, the higher the risk of developing rabies is. This study aimed to investigate the severity of wounds among animal bite victims and identify the influencing factors in Wuhan, China.

Methods

A cross-sectional study was conducted among 1015 animal bite victims visiting rabies prevention clinics. We performed a face-to-face interview to collect information on the exposure category of the bite wound, the type of the offending animal, exposure-to-risk situations, etc. Factors associated with exposure categories were identified by multivariate logistic regression analysis.

Results

Five hundred and sixty-four (55.57%) cases were category III exposures, 418 (41.18%) were category II exposures, and 33 (3.25%) were category I exposures. People who were hurt by their own domestic animals (odds ratio [OR] = 1.55, 95% confidence interval [CI]: 1.14–2.10), and those exposed to animals unvaccinated against rabies (OR = 1.45, 95% CI: 1.08–1.95) had a higher risk for category III exposures. Respondents who did not know the fatality of rabies were more likely to be injured seriously compared to those who knew that rabies is fatal, and the OR was 1.40 (95% CI, 1.05–1.86).

Conclusions

This study showed that factors associated with the severity of bite wounds mainly included types of the offending animal, vaccination status of the animal, and knowledge of rabies fatality. Educational programs and awareness-raising campaigns should be provided to decrease severe animal bites, especially targeting pet owners and those with limited rabies knowledge.

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.

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.

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.

Dog ownership practices and responsibilities for children's health in terms of rabies control and prevention in rural communities in Tanzania

Interventions tackling zoonoses require an understanding of healthcare patterns related to both human and animal hosts. The control of dog-mediated rabies is a good example. Despite the availability of effective control measures, 59,000 people die of rabies every year worldwide. In Tanzania, children are most at risk, contributing ~40% of deaths. Mass dog vaccination can break the transmission cycle, but reaching the recommended 70% coverage is challenging where vaccination depends on willingness to vaccinate dogs. Awareness campaigns in communities often target children, but do not consider other key individuals in the prevention chain. Understanding factors related to dog ownership and household-level responsibility for dog vaccination and child health is critical to the design of vaccination strategies. We investigated who makes household decisions about dogs and on health care for children in rural Tanzania. In the Kilosa district, in-depth interviews with 10 key informants were conducted to inform analysis of data from a household survey of 799 households and a survey on Knowledge Attitudes and Practices of 417 households. The in-depth interviews were analysed using framework analysis. Descriptive analysis showed responsibilities for household decisions on dogs' and children's health. Multivariate analysis determined factors associated with the probability of dogs being owned and the number of dogs owned, as well as factors associated with the responsibility for child health. Dog ownership varied considerably between villages and even households. The number of dogs per household was associated with the size of a household and the presence of livestock. Children are not directly involved in the decision to vaccinate a dog, which is largely made by the father, while responsibility for seeking health care if a child is bitten lies with the mother. These novel results are relevant for the design and implementation of rabies interventions. Specifically, awareness campaigns should focus on decision-makers in households to improve rabies prevention practices and on the understanding of processes critical to the control of zoonoses more broadly.

Using geostatistics to better understand the epidemiology of animal rabies in Morocco: what is the contribution of the predictive value?

This study aims to characterize the spatial distribution of animal rabies in Morocco in order to provide appropriate control approaches. Descriptive analyses of the epidemiological data show that the number of reported canine rabies cases greatly underestimates the true incidence of the disease. Underreporting subsequently affects the coherence of its spatial distribution. To perform accurate geographic distribution mapping of the disease based on interpolation methods, a data set was created using data between 2000 and 2018 to compare the derived disease cases with known true values in order to identify disease clusters. The subsequent interpolation was conducted using Ordinary Kriging regression methods and the semi variogram to focus on short distances and reduce uncertainty. The estimated clusters of rabies were evaluated using a cross validation step which revealed predicted cases close to the true values. To improve the precision of analysis, the authors displayed georeferenced dog and human rabies cases reported during the last three years, demonstrating reliable results that correspond to the estimated cluster areas similar to the true disease incidence on the field. This work highlights a strong correlation between infrastructure projects (i.e. railways, roads, facilities) and rabies epizootics for several specific locations. This study is the first attempt to use geostatistics to build upon the understanding of animal rabies in Morocco and shed light on the most appropriate strategies to sustainably reduce and mitigate the risk of rabies. There has been little literature on the use of kriging methods in animal health research. Thus, this study also aimed to explore a novel method in the veterinary sciences to establish kriging as a valid and coherent analysis tool to identify the extent to which the geostatistic area can objectively support understanding on animal rabies and saw it as being highly instrumental in coping with gaps in the data.

Improving dog bite victim survey and estimation of annual human deaths due to suspected rabies cases in three selected Liberian cities and environs, 2008-2017

Rabies remains a public health challenge of unknown magnitude in Liberia in spite of the goal of ensuring that no human in the country dies of rabies by 2030. The annual prevalence of Dog Bite Victims (DBVs) and true load of Annual Human Deaths (AHDs) due to rabies were not known. We investigated three selected cities of Liberia for annual prevalence of DBVs and true load of AHD due to suspected rabies, using 10-year retrospective record, 2008-2017 obtained from Buchanan, Gbarnga, and Voinjama, three socio-economically important cities in post-conflict Liberia. Data were sourced at County Reference Hospitals and at the Liberia National Institute of Health for these cities and their local environs. In addition, household questionnaire survey was used to identify and audit data quality for unreported DBVs, and treatment received from traditional caregivers. The proportion was used to audit the 10-year data on unreported DBVs in the cities. Descriptive statistics was used to summarize annual DBVs over the 10-year period in the three cities, respectively. A standardized clinical decision tree model was used to estimate AHDs due to suspected rabies. Based on questionnaire survey, 140/365, 148/375 and 146/350 DBVs did not visit any orthodox health facility in Buchanan, Gbarnga and Voinjama cities, respectively in 2014. An estimated total of 559 DBVs died of suspected rabies in the three cities and their environs during the 10-year period. Mean yearly prevalence of DBVs was 179±106.82, 393±257.85 and 76.9±38.11 per 100,000 population, while mean AHDs due to suspected rabies was 14.3±8.47, 35.5±23.25, and 6.1±3.21 per 100,000 population in Buchanan, Gbarnga, and Voinjama cities, respectively. The present findings provide annual prevalence of suspected rabies cases, corrected for under-reporting in three selected cities of Liberia. The findings would be useful in planning for stepwise actions towards rabies elimination, ensuring that no human dies of rabies in Liberia by 2030.

Epidemiological study of human rabies cases in Bangladesh through verbal autopsy

Identification of risk factors is crucial to find ways to reduce rabies deaths. We investigated the hospital records of rabies deceased through contact tracing of the relatives of the victims using enhanced verbal autopsies (VA) to identify why the people had to die from rabies in recent years in Bangladesh. Patients whose deaths were confirmed by physicians based on the history of animal exposure and clinical signs were taken into account for VA. Socio-demographic profile of the deceased, animal exposure, nature of the wound, and history of post-exposure prophylaxis (PEP) data were obtained and analysed. The study found 256 cases in which the cause of death was attributed to rabies, most of the victims were male (71.88%), resided in the rural community (80.47%), dependent (49.22%), and children below the age of 15 years (47.27%). Dogs were the single most responsible (81.64%); however, cats (12.11%), jackals (3.91%) and mongoose (2.34%) were also found accountable for rabies incidence (P < 0.05). Significantly, limbs were the most common (67.97%) site of exposure, and the shortest incubation period was identified in the case of bites to head and face (P < 0.05). The majority (86.72%) of the deceased did not receive any PEP; whereas, 66.80% sought treatment from traditional healers. Among the deceased (13.28%, n = 34) who had received PEP, only 8.82% of them completed the full course of the vaccination regimen (P < 0.01); however, none of them had history of taking rabies immunoglobulin (RIG). The study recommends extensive public health awareness programs in the rural community and establishing methods to improve healthcare-seeking behaviours, including receiving PEP instead of visiting traditional healers. Moreover, the availability and accessibility of PEP in the government hospital facilities are desirable, and laboratory-based surveillance with compatible rapid data reporting may be incorporated in the existing policy.

Incidence of Animal-Bite Injuries Registered in Public Hospitals of Post-Conflict Swat District, Pakistan in 2014

The Swat district, a conflict-hit territory due to Taliban militancy, had a damaged local health infrastructure. Animal-bite injuries leading to rabies is one of the major health concerns in developing countries, especially within conflict zones. The current prospective epidemiological study was conducted to estimate the cumulative incidence of animal-bite injuries, to summarize characteristics of bite victims and biting animals, and to collect information about post-exposure prophylaxis (PEP) practices in Swat district, Pakistan, during 2014. A questionnaire was designed to collect data about the sociodemography of the patients, bite incident situation (provoked or unprovoked), injury pattern, animal type, PEP, and vaccination. Descriptive analyses were conducted using bar graphs, frequency tables, and chi-square tests were used to determine associations. The cumulative incidence of animal-bite injuries was 39 per 100,000 people during the study period (May-August 2014). The majority of incidents were reported from rural regions (77.7%) and were males (76.6%) younger than 10 years (37.3%). Dogs were the most frequent biting animal (86.8%) followed by rats (4.7%). About 77.7% patients washed their wound before arrival at hospital. After an eclipse phase of 10 days, 44 (10.1%) animals developed sign of rabies. The current study has highlighted a topic of interest for health, education, veterinary, and local government policy makers regarding prevention of animal bites, benefits of PEP, vaccination of human and domestic animals, control of stray dogs, and eradication of rabies in developing countries with damaged healthcare structures.

Policy Perspectives of Dog-Mediated Rabies Control in Resource-Limited Countries: The Ethiopian Situation

One Health disease-control programs are believed to be most effective when implemented within the population transmitting the disease. The World Health Organization (WHO) and partners have targeted the elimination of dog-mediated human rabies by 2030 primarily through mass dog vaccination. Mass vaccination, however, has been constrained by financial resource limitations. The current owner-charged dog vaccination strategy, used in most resource-limited countries like Ethiopia, has not reached the minimum coverage required to build population immunity. Dog vaccination is non-existing in most rural areas of Ethiopia, and coverage is <20% in urban areas. Although the health and economic benefits of rabies elimination outweigh the costs, the direct beneficiaries (public in general) and those who bear the costs (dog owners) are not necessarily the same. In this perspective paper, we aggregate evidence on the socioeconomic burden of rabies in Ethiopia as well as the implications for potential opportunities to control the disease and possibilities to obtain the required funding sources for evidence-based interventions in the control of rabies in Ethiopia.

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.

Knowledge and attitudes about rabies in dog-bite victims in Bangladesh

Rabies is an important zoonotic disease that causes several thousand deaths in Asian countries. Bangladesh launched an elimination programme in 2010 based on the mass vaccination of dogs, management of dog bites, application of post-exposure prophylaxis and communication and social mobilization. The aim of this study is to ascertain the behaviour of and knowledge about dog-bite victims.

A cross-sectional descriptive study was performed on 885 dog-bite victims who presented themselves for post-exposure rabies vaccination to six randomly selected vaccination centers, in addition to a tertiary-level hospital in Bangladesh. Most dog-bite victims were male (70%) and with very low or no education qualifications (75%). Respondents' knowledge of rabies was low: 58% were unaware of the consequences of a dog bite and 52% did not know about any indication of rabies. Most knew that rabies in humans can be prevented after dog bites, but up to 70% did not give a correct answer for other questions related to the prevention and treatment of rabies. Knowledge and attitudes about rabies is closely related to level of education. Finally, 58 of those surveyed (6.4%) did not complete the post-exposure prophylaxis correctly.

In conclusion, knowledge about rabies among Bangladeshi citizens is low. An intensive plan to inform and educate people about dog bites, the risk of rabies and measures to adopt for preventing the disease should be implemented in order to reduce risk, including the need to complete post-exposure treatment.

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Knowledge about rabies in victims of dog bites in Bangladesh was low (58% were unaware of the consequences of a dog bite).

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Up to 70% of bite victims did not give a correct answer to some questions related to prevention and treatment of rabies.

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A small but significant proportion of dog-bite victims (6.4%) did not complete the Post-Exposure prophylaxis correctly.

Evaluation of post-exposure prophylaxis practices to improve the cost-effectiveness of rabies control in human cases potentially exposed to rabies in southern Bhutan

BACKGROUND

Rabies is endemic in southern Bhutan, associated with 1-2 human deaths and high post exposure prophylaxis (PEP) costs annually. Evaluation of clinicians' management of human cases potentially exposed to rabies could contribute to improving PEP prescribing practices to both reduce unnecessary costs associated with PEP and reach the target of zero human deaths due to rabies by 2023.

METHODS

A cross-sectional survey of 50 clinicians' management of human cases potentially exposed to rabies was conducted in 13 health centers in high-rabies-risk areas of Bhutan during February-March 2016.

RESULTS

Data were collected on clinicians' management of 273 human cases potentially exposed to rabies. The 50 clinicians comprised health assistants or clinical officers (55%) and medical doctors (45%) with a respective median of 19, 21 and 2 years' experience. There was poor agreement between clinicians' rabies risk assessment compared with an independent assessment for each case based on criteria in the National Rabies Management Guidelines (NRMG). Of the 194 cases for which clinicians recorded a rabies risk category, only 53% were correctly classified when compared with the NRMG. Clinicians were more likely to underestimate the risk of exposure to rabies and appeared to prescribe PEP independently of their risk classification.. Male health assistants performed the most accurate risk assessments while female health assistants performed the least accurate. Clinicians in Basic Health Units performed less accurate risk assessments compared with those in hospitals.

CONCLUSIONS

This study highlights important discrepancies between clinicians' management of human cases potentially exposed to rabies and recommendations in the NRMG. In particular, clinicians were not accurately assessing rabies risk in potentially exposed cases and were not basing their PEP treatment on the basis of their risk assessment. This has significant implications for achieving the national goal of eliminating dog-mediated human rabies by 2030 and may result in unnecessary costs associated with PEP. Recommendations to improve clinician's management of human cases potentially exposed to rabies include: reviewing and updating the NRMG, providing clinicians with regular and appropriately targeted training about rabies risk assessment and PEP prescription, and regularly reviewing clinicians' practices.

An epidemiological study of suspected rabies exposures and adherence to rabies post-exposure prophylaxis in Eastern Thailand, 2015

Background

Human rabies is a notifiable condition in Thailand, and 46 confirmed and probable cases were reported from 2010–2015; eleven were reported from Eastern Thailand. Although rabies is vaccine preventable, more than 90% of persons who died of rabies in Thailand either did not receive or inappropriately discontinued post-exposure prophylaxis (PEP). In 2012 Thailand launched a national animal rabies elimination program with the goal of elimination by 2020. One of the policies of this national program is to improve detection of animal rabies exposures, access to PEP, and adherence to vaccine schedules. To achieve this goal, several hospital-based electronic PEP surveillance systems have been instituted throughout Thailand.

Method

Data from a voluntary, electronic hospital-based, rabies exposure and PEP surveillance system was analyzed from eight provinces in Eastern Thailand for the time period January 1 –December 31, 2015. The surveillance system collects data from all persons who present to an R36-integrated healthcare facility with a suspected rabies exposure, including characteristics of the biting animals, categorization of the rabies exposure, and adherence to PEP recommendations. The crude rate of healthcare seeking for a suspected rabies exposure was assessed by province, and a multivariable linear regression model was developed to determine the potential extent of undetected rabies exposures due to bite treatment at healthcare facilities that do not utilize the R36 system. Suspected rabies exposures were described by patient demographics, location of wound, and disposition of the offending animal. A comparison of adherence to intramuscular and intradermal vaccination regimens was performed and odds ratios were calculated for factors related to unadvised PEP discontinuation.

Result

6,204 suspected rabies exposures were reported from eight Eastern Thailand provinces, yielding a crude exposure rate of 106 reported rabies exposures per 100,000 population. When adjusted for under-detection due to non-participating hospitals and province-level demographic differences, the estimated suspected rabies exposure rate was 204/100,000. Dogs were the main source of exposure (77.8%) and children age <15 years and elderly age >60 years had the highest overall reported exposure rate (189.7 and 189.2/100,000). Adherence to either the intramuscular 5-dose or the intradermal 4-dose PEP regimen was low (15.8% and 46.5%, respectively); rabies immunoglobulin was received by only 15% of persons for whom it was indicated. Persons with rabies exposures were more likely to discontinue the vaccination series against medical advice if they were male, aged 16–45, if they received immunoglobulin, or if received the intramuscular regimen.

Conclusion

When adjusting for number of reporting hospitals, province population density, number of hospitals per population and average family income, the expected report rate increased 1.9-fold, indicating that there is likely a high level of under-detection of persons seeking medical care for suspected rabies exposures. Expanded implementation of electronic surveillance systems will likely improve reporting and the epidemiologic knowledge of rabies exposures. Analysis of data collected from this system revealed very low rates of adherence to rabies vaccination recommendations. PEP adherence was better by the intradermal route, which provides more support for its use in situations where it is economically feasible.

While rabies is a vaccine preventable disease, and despite tremendous improvements in access to healthcare, human rabies fatalities continue to occur in Thailand. Data from a voluntary, electronic hospital-based, rabies exposure and PEP surveillance system was analyzed from eight provinces in Eastern Thailand. In total 6,204 suspected rabies exposures were reported between January 1 –December 31, 2015, yielding a crude exposure rate of 106 reported rabies exposures per 100,000 population or 204/100,000 when adjusted for under-reporting. Dogs were the main sources of exposure and children age < 15 years and elderly aged > 60 years had the highest overall reported exposure rate. Adherence to either the intramuscular or the intradermal PEP regimen was low (15.8% for IM and 46.5% for ID). There is likely a high level of under-detection of persons seeking medical care for suspected rabies exposures in Eastern Thailand, but expanded implementation of electronic surveillance systems will likely improve reporting. Further investigation is needed to understand why rates of adherence to PEP were low. Adherence was better by the intradermal route, which provides more support for its use in situations where it is economically feasible.

Trends and clinico-epidemiological features of human rabies cases in Bangladesh 2006-2018

Vaccinating dogs against rabies is an effective means of reducing human rabies. We subjected 1327 clinically diagnosed human rabies death and mass dog vaccination (MDV) data during 2006-2018 to quantify the impacts of MDV on human rabies incidence in Bangladesh and a subset of rabies death data (422) for clinico-epidemiological analysis. A positive and increasing trend of MDV (p = 0.01 and tau = 0.71) and a negative and declining trend (p < 0.001 and tau = -0.88) of human rabies cases (Correlation coefficient: -0.82) have been observed. Among 422 deaths, the majority (78%) of the victims sought treatment from traditional healers, and 12% received post-exposure prophylaxis (PEP). The mean incubation period of rabies in cases with exposure sites on the head & neck (35 days) was shorter than the upper limb (mean = 64 days, p = 0.02) and lower limb (mean = 89 days, p < 0.01). MDV has been found to be effective for reducing human rabies cases in Bangladesh. Creating awareness among the animal bite victims to stop reliance on traditional healers rather seeking PEP, addressing the role of traditional healers through awareness education programme with respect to the treatment of dog bites, ensuring availability of PEP, and continuing to scale up MDV may help to prevent human rabies deaths.

Can sterilization help to prevent roaming in owned dogs and cats?

In many locations, the highest proportion of roaming dogs and cats, might have owners. The prevention of roaming in owned dogs and cats is a key intervention to reduce the number of unsupervised animals in public spaces. Sterilization is an important population management intervention but it is unclear if, apart from its effects on birth rates and animal behavior, it also affects the roaming status of owned dogs and cats. We formulated a directed acyclic graph to represent a causal hypothesis regarding the effect of sex, age and sterilization on roaming behavior in owned dogs and cats. The causal hypothesis was tested using survey data and Bayesian multilevel logistic regressions. The odds of roaming were lower in sterilized dogs and cats but the credible interval (CI) supported the effect of sterilization only for dogs. The odds of roaming were higher in both male dogs and cats and the CI supported the effect of sex. The CI did not support the effect of age on roaming, irrespective of species. If the observed association between sterilization and roaming was causal, then sterilization may contribute to a reduction in roaming. Studies on other populations and the exploration of other potential determinants of roaming are required to better understand the causal relationship between sterilization and roaming.

On the path to rabies elimination: The need for risk assessments to improve administration of post-exposure prophylaxis

BACKGROUND

Costs of rabies post-exposure prophylaxis (PEP) often remain high in regions where rabies has been controlled in dogs, presenting a challenge for sustaining rabies elimination programmes. We investigated the potential for bite patient risk assessments to improve PEP provision and surveillance in settings approaching elimination of dog-mediated rabies.

METHODS

We conducted a longitudinal study of patients presenting to animal bite treatment centres (ABTCs) on the island province of Bohol in the Philippines to investigate the health status of biting dogs and to quantify current expenditure on PEP.

RESULTS

Incidence of bite patients presenting to ABTCs was high (>300/100,000 persons/year) and increasing, resulting in substantial health provider costs. Over $142,000 was spent on PEP in 2013 for a population of 1.3 million. From follow up of 3820 bite patients we found that  >92% were bitten by healthy dogs (alive 14 days after the bite) and just 1.4% were bitten by probable or confirmed rabid dogs. The status of dogs that bit 6% of patients could not be determined. During the course of investigations of bites by suspect dogs, we were able to obtain samples for case confirmation, identify exposed persons who had not sought PEP as well as in-contact dogs at risk of developing rabies. We calculate that expenditure on PEP could at least be halved through more judicious approaches to provision of PEP, based on the histories of biting animals determined through risk assessments with bite patients.

CONCLUSIONS

We conclude that a One Health approach to surveillance based on Integrated Bite Case Management could improve the sustainability and effectiveness of rabies elimination programmes while also improving patient care by identifying those genuinely in need of lifesaving PEP.

Healthcare utilization, provisioning of post-exposure prophylaxis, and estimation of human rabies burden in Madagascar

In Madagascar, dog-mediated rabies has been endemic for over a century, however there is little data on its incidence or impact. We collected data over a 16-month period on provisioning of post-exposure prophylaxis (PEP) at a focal clinic in the Moramanga District and determined the rabies status of biting animals using clinical and laboratory diagnosis. We find that animal rabies cases are widespread, and clinic-based triage and investigation are effective ways to increase detection of rabies exposures and to rule out non-cases. A high proportion of rabies-exposed persons from Moramanga sought (84%) and completed PEP (90% of those that initiated PEP), likely reflecting the access and free provisioning of PEP in the district. Current clinic vial sharing practices demonstrate the potential for intradermal administration of PEP in endemic African settings, reducing vaccine use by 50% in comparison to intramuscular administration. A high proportion of PEP demand was attributed to rabies cases, with approximately 20% of PEP administered to probable rabies exposures and an additional 20% to low-to-no risk contacts with confirmed/probable animal or human cases. Using a simplified decision tree and our data on rabies exposure status and health-seeking behavior, we estimated an annual incidence of 42-110 rabies exposures and 1-3 deaths per 100,000 persons annually. Extrapolating to Madagascar, we estimate an annual burden of 282-745 human rabies deaths with current PEP provisioning averting 1499-3958 deaths each year. Data from other clinics and districts are needed to improve these estimates, particularly given that PEP availability is currently limited to only 31 clinics in the country. A combined strategy of mass dog vaccination, enhanced surveillance, and expanded access to PEP along with more judicious guidelines for administration could effectively reduce and eventually eliminate the burden of rabies in Madagascar.

Dog Ecology, Bite Incidence, and Disease Awareness: A Cross-Sectional Survey among a Rabies-Affected Community in the Democratic Republic of the Congo

Despite the existence of safe and efficacious human and animal rabies vaccines, millions of people remain at risk of exposure to this deadly zoonotic disease through bites of infected dogs. Sub-Saharan African countries, such as the Democratic Republic of the Congo (DRC), bear the highest per capita death rates from rabies where dog vaccination and availability of lifesaving post-exposure prophylaxis (PEP) is scarce. Mass dog vaccination is the most cost-effective and sustainable approach to prevent human rabies deaths. We conducted a cross-sectional household survey in a rabies-affected community in Matadi, DRC, to estimate the size of the owned dog population and dog bite incidence and assess knowledge and practices regarding rabies, as preparation for future mass dog vaccination campaigns. Our study revealed that the owned dog population in Matadi was almost ten times larger than assumed by local veterinary officials, with a large proportion of free-roaming unvaccinated dogs. The annual dog bite incidence of 5.2 per 1000 person years was high, whereas community rabies knowledge was low resulting in poor practices. Given these findings, human rabies deaths are likely to occur in this community. Lack of disease awareness could negatively affect participation in future mass dog vaccination campaigns. A public sensitization campaign is needed to promote appropriate rabies prevention (washing bite wounds and PEP) and control (dog vaccination) measures in this community.

Risk of human exposure to animal bites in China: a clinic-based cross-sectional study

Human exposure to animal bites is the most important public health concern in relation to rabies transmission. This study aims to determine the factors associated with human exposure to animal bites in China. A cross-sectional study of visitors to rabies prevention clinics who were seeking treatment because of exposure to animal bites or scratches was conducted in Wuhan, China. Humans exposed to animal bites (n = 1015) were interviewed, and 87% of the bites were attributed to domestic animals. The risk types for animal bites included unprovoked aggression (31.7%), excessive play (27.5%), insufficient preparedness (26.7%), and improper care of animals (14.1%). Children aged 1-15 years (OR = 9.069, 95% CI: 4.572-17.987, P < 0.001) were more likely to be injured because of excessive play. Nonvaccinated people (OR = 2.168, 95% CI: 1.034-4.545, P = 0.040) and people who discontinued the rabies vaccine regimen (OR = 2.600, 95% CI: 1.561-4.331, P < 0.001) were at risk of rabies exposure and were more likely to be injured because of improper care of animals. This study showed that domestic animals were responsible for most animal bites. The associated factors were age, educational attainment, and animal ownership. Community health education with a special attention to schoolchildren and animal owners should be provided.

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.

Cost Savings of Using Updated Thai Red Cross Intradermal Regimen in a High-Throughput Anti-Rabies Clinic in New Delhi, India

Replacement of the Essen intramuscular (EIM) by the updated Thai Red Cross intradermal (UTRCID) regimen for rabies post-exposure prophylaxis (PEP), in high-throughput hospitals of India, has been advocated since 2006 thanks to its cost-effectiveness. However, several anti-rabies clinics in India and other parts of the world have not initiated this switchover of regimens because of the paucity of financial literature, generated in realistic settings, regarding the same. We calculated the procurement costs of various items required for providing rabies vaccinations via the EIM regimen and UTRCID regimen, on an annual basis, a year before and after the switchover. From a healthcare provider's perspective, the cost of vaccination per patient was calculated to be 5.60 USD for the EIM regimen and 2.40 USD for the UTRCID regimen. The switchover to the UTRCID regimen from the EIM regimen reduced the financial burden of the rabies vaccination by almost 60%. Procurement of vaccine vials contributed to the majority of the cost (>94%) in both of the regimens. Procurement of syringes with fixed needles contributed negligibly (<6%) to the financial burden in both the regimens. A policy to progressively switch over to the UTRCID regimen from the EIM in all high-throughput anti-rabies centers of India would dramatically reduce the economic burden of running a successful anti-rabies program.

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.

The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania

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Prompt post-exposure vaccination is extremely effective in preventing human rabies.

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Intradermal post-exposure vaccination is easily adopted by health workers in Tanzania.

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High costs of PEP to government affect the supply chain and limit its availability.

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Limited PEP supply results in higher out-of-pocket payments and increased risks.

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Investment to facilitate free PEP provision would reduce rabies deaths.

Background

Rabies is preventable through prompt administration of post-exposure prophylaxis (PEP) to exposed persons, but PEP access is limited in many rabies-endemic countries. We investigated how access to PEP can be improved to better prevent human rabies.

Methods

Using data from different settings in Tanzania, including contact tracing (2,367 probable rabies exposures identified) and large-scale mobile phone-based surveillance (24,999 patient records), we estimated the incidence of rabies exposures and bite-injuries, and examined health seeking and health outcomes in relation to PEP access. We used surveys and qualitative interviews with stakeholders within the health system to further characterise PEP supply and triangulate these findings.

Results

Incidence of bite-injury patients was related to dog population sizes, with higher incidence in districts with lower human:dog ratios and urban centres. A substantial percentage (25%) of probable rabies exposures did not seek care due to costs and limited appreciation of risk. Upon seeking care a further 15% of probable rabies exposed persons did not obtain PEP due to shortages, cost barriers or misadvice. Of those that initiated PEP, 46% did not complete the course. If no PEP was administered, the risk of developing rabies following a probable rabies exposure was high (0.165), with bites to the head carrying most risk. Decentralized and free PEP increased the probability that patients received PEP and reduced delays in initiating PEP. No major difficulties were encountered by health workers whilst switching to dose-sparing ID administration of PEP. Health infrastructure also includes sufficient cold chain capacity to support improved PEP provision. However, high costs to governments and patients currently limits the supply chain and PEP access. The cost barrier was exacerbated by decentralization of budgets, with priority given to purchase of cheaper medicines for other conditions. Reactive procurement resulted in limited and unresponsive PEP supply, increasing costs and risks to bite victims.

Conclusion

PEP access could be improved and rabies deaths reduced through ring-fenced procurement, switching to dose-sparing ID regimens and free provision of PEP.

Long term trends and spatial distribution of animal bite injuries and deaths due to human rabies infection in Uganda, 2001-2015

BACKGROUND

In the absence of accurate data on trends and the burden of human rabies infection in developing countries, animal bite injuries provide useful information to bridge that gap. Rabies is one of the most deadly infectious diseases, with a case fatality rate approaching 100%. Despite availability of effective prevention and control strategies, rabies still kills 50,000 to 60,000 people worldwide annually, the majority of whom are in the developing world. We describe trends and geographical distribution of animal bite injuries (a proxy of potential exposure to rabies) and deaths due to suspected human rabies in Uganda from 2001 to 2015.

METHODS

We used 2001-2015 surveillance data on suspected animal bite injuries, collected from health facilities in Uganda. To describe annual trends, line graphs were used and linear regression tested significance of observed trends at P<0.05. We used maps to describe geographical distribution of animal bites by district.

RESULTS

A total of 208,720 cases of animal bite injuries were reported. Of these, 27% were in Central, 22% in Eastern, 27% in Northern and 23% in Western regions. Out of 48,720 animal bites between 2013 and 2015, 59% were suffered by males and 81% were persons aged above 5 years. Between 2001 and 2015, the overall incidence (per 100,000 population) of animal bites was 58 in Uganda, 76 in Northern, 58 in Central, 53 in Western and 50 in Eastern region. From 2001 to 2015, the annual incidence (per 100,000 population) increased from 21 to 47 (P = 0.02) in Central, 27 to 34 (P = 0.04) in Eastern, 23 to 70 (P = 0.01) in Northern and 16 to 46 (P = 0.001) in Western region. A total of 486 suspected human rabies deaths were reported, of which 29% were reported from Eastern, 28% from Central, 27% from Northern and 17% from Western region.

CONCLUSION

Animal bite injuries, a potential exposure to rabies infection, and mortality attributed to rabies infection are public health challenges affecting all regions of Uganda. Eliminating rabies requires strengthening of rabies prevention and control strategies at all levels of the health sector. These strategies should utilize the "One Health" approach with strategic focus on strengthening rabies surveillance, controlling rabies in dogs and ensuring availability of post exposure prophylaxis at lower health facilities.

P. An exploratory study on rabies exposure through contact tracing in a rural area near Bengaluru, Karnataka, India

NEED FOR STUDY

Rabies is a neglected zoonotic disease. Given the low incidence, apart from the existing reporting syst, there is a need to look for other means of case detection strategies for rabies. Contact tracing is one such method to efficiently capture information.

OBJECTIVES

To find out the rabid status of biting animal through contact tracing and to determine health seeking behavior of the bite victims.

MATERIALS AND METHODS

An exploratory study using contact tracing was conducted during the first quarter of 2017 in villages coming under three Public Health Centers. The households of the bite victims were visited and details of rabies exposure obtained from the bite victim/ adult responsible respondent using a standardized questionnaire.

RESULTS

A total of 69 dog/cat bite cases were identified. 69.5% of bites were by stray dogs. 97.1% bite victims had Category III bites. Only 4.5% bite victims had taken PEP. 70.1% of animal bite cases were administered ARV. Only 7.2% bite victims had exposure to probable rabid animals. All dog bite victims were alive after 3 months of follow up.

CONCLUSION

Contact tracing was successful in case detection of probable rabid animal exposures and suitable for a period of one year.

Rabies elimination research: juxtaposing optimism, pragmatism and realism

More than 100 years of research has now been conducted into the prevention, control and elimination of rabies with safe and highly efficacious vaccines developed for use in human and animal populations. Domestic dogs are a major reservoir for rabies, and although considerable advances have been made towards the elimination and control of canine rabies in many parts of the world, the disease continues to kill tens of thousands of people every year in Africa and Asia. Policy efforts are now being directed towards a global target of zero human deaths from dog-mediated rabies by 2030 and the global elimination of canine rabies. Here we demonstrate how research provides a cause for optimism as to the feasibility of these goals through strategies based around mass dog vaccination. We summarize some of the pragmatic insights generated from rabies epidemiology and dog ecology research that can improve the design of dog vaccination strategies in low- and middle-income countries and which should encourage implementation without further delay. We also highlight the need for realism in reaching the feasible, although technically more difficult and longer-term goal of global elimination of canine rabies. Finally, we discuss how research on rabies has broader relevance to the control and elimination of a suite of diseases of current concern to human and animal health, providing an exemplar of the value of a ‘One Health’ approach.

Post-exposure prophylaxis (PEP) for rabies with purified chick embryo cell vaccine: a systematic literature review and meta-analysis

INTRODUCTION

Fifteen million people each year receive post-exposure prophylaxis (PEP) to prevent rabies, yet the disease remains neglected and highly under-reported.

AREAS COVERED

In this systematic literature review, we assessed the immunogenicity, efficacy, and safety of a purified chick embryo cell-culture rabies vaccine (PCECV) for PEP against rabies by intramuscular (IM) or intradermal (ID) administration. We performed meta-analyses to compare immunogenicity according to the route of vaccine administration, study population, and PEP regimen, such as number of doses, and concomitant rabies immunoglobulin.

EXPERT COMMENTARY

There were 54 estimates of immune responses to vaccination, which showed that in the overall population, after starting PEP with PCECV by the IM or ID route (≥2.5 IU per dose), almost all individuals had rabies virus neutralizing antibody (RVNA) titers above the World Health Organization (WHO) recommended serological threshold for an adequate immune response to vaccination (RVNA ≥0.5 IU/ml by day 14). In the overall population, PCECV had an acceptable safety profile. However, given that there are 59,000 human rabies deaths reported annually, the challenge is to improve access to PCECV for PEP against human rabies.

A STUDY OF CORRELATION BETWEEN AGENT, HOST, ENVIRONMENT AND VACCINE FACTORS WITH PREVALENCE OF RABIES IN INDONESIA 2015

A zoonotic disease has been global threat related to health and one of them is rabies. More than 150 countries around the world has infected by rabies disease problem and the case fatality rate (CFR) reaches 100%, which there are 55,000 people died every year because of rabies. In Indonesia, there are 25 from 34 province, which has endemic of rabies disease. The purpose of this study is to know the correlation between the factors of the agent, host, and environment and also anti rabies vaccine with the prevalence of rabies in Indonesia at 2015. The study used correlation design which using Indonesian zoonotic reported data by Ministry of Health and also used other secondary data, which is provided by central bureau of statistic Indonesia (BPS).  The provinces that included in this study are the endemic provinces associated with the rabies incident that reported to Ministry of Health and have the completeness of data in 2015. A total of 22 provinces was included in this study, which only use Rabies cases from dog’s bite only. Rabies that source from others animal’s bite could not included in this study because of data limitations. This study used simple linear of regression statistical tests through provincial as unit analysis. The result of this study showed that there were correlations between agent that have positive specimens (r=0.606, P value =0.0003), status of working participation rate (r=0.435, P value 0.004) and also coverage of rabies vaccine (r=-0.567, P value =0.041) with the prevalence of rabies disease. In summary, there are a positive correlation between positive specimen of agent and also status of working participant rate with the prevalence of rabies disease. However, rabies vaccine coverage has negative correlation. Furthermore, there is no correlation between environment factors and prevalence of rabies disease in this study. It still need further research to be more research on a smaller level with variables that varied.