Between 1992 and 2002, rabies post-exposure prophylaxis
(PEP) was given to 86 Slovenian travellers returning from abroad and 2011
people potentially exposed in Slovenia. During this time, there was a significant
increase in prophylaxis given to returning international travellers, but no
significant change in annual prophylaxis given to those potentially exposed
in Slovenia. Most of those people returning from abroad who required PEP,
had travelled to regions where rabies is enzootic (endemic in animals), and
had been bitten most often by dogs, monkeys or cats.
There are only a few human cases of rabies in Europe reported each year,
mainly in travellers returning from abroad [1-3]. The rabies situation in
humans is generally under control [4-6] except of rare human rabies cases
in European part of Russia, Turkey and Romania. In Slovenia, when a patient
reports an animal bite, the risk of rabies virus infection is assessed by
an antirabies centre using a standardized questionnaire. Inactivated rabies
vaccine (Rabivac, Chiron Vaccines, Germany) and human rabies immunoglobulin
produced by Chiron, Marburg or Imunuloški Zavod, Zagreb, are used for PEP.
The incidence of rabies PEP in Slovenia per 100 000 population was calculated
using annual population numbers from the Statistical Office of the Slovenian
Republic. Time trend analysis was performed to detect an association between
the year and the number of cases, and PEP incidence separately in domestic
populations and international travellers.The average age of travellers was
34 years (range: 3 - 95), 46 males and 40 females (Table 1).
Table 1. Annual incidence per 100 000 population of post-exposure
treatment against rabies, Ljubljana region, 1992-2002
| Year |
|
1992 |
1993 |
1994 |
1995 |
1996 |
1997 |
1998 |
1999 |
2000 |
2001 |
2002 |
| International travellers from Slovenia |
Number |
4 |
7 |
1 |
6 |
8 |
4 |
3 |
6 |
16 |
15 |
16 |
| Incidence |
0.7 |
1.2 |
0.2 |
1 |
1.3 |
0.7 |
0.5 |
1 |
2.7 |
2.5 |
2.7 |
| Domestic |
Number |
185 |
221 |
186 |
232 |
185 |
133 |
133 |
181 |
211 |
183 |
161 |
| Incidence |
31.2 |
37.3 |
31.4 |
39.5 |
30.9 |
22.6 |
22.3 |
30.4 |
35.2 |
30.4 |
26.7 |
From 1992-2002, there was a four-fold increase in PEP given to international
travellers, from 0.7 in 1992 to 2.7 per 100 000 population in 2002. This
increase happened mainly in 2000, 2001 and 2002 and we suspect that this
is due to recent increased tourism to south Asia, and increasing awareness
of rabies among tourists traveling to Croatia and Bosnia and Herzegovina
[7].
Slovenian travellers were treated after returning from:
|
- Bosnia and Herzegovina (14 patients)
|
|
|
- Gibraltar, Hungary, Romania, Peru, Serbia, Sri Lanka and Austria
– 2 cases per country
|
- Burundi, China, Egypt, France, Gambia, Ghana, Greece, India, Kenya,
Malaysia, Russia, Tunisia, Turkey and the United States– 1 case
per country
|
Travellers were bitten by a number of different animals, mostly dogs whose
owners were unknown (Table 2). Dog bites were the most common reason for
rabies PEP being given in both groups (72% of travellers and 64% of domestic
cases).
Table 2. Animal sources of suspect rabies exposure in
international travellers from Slovenia
| Animal |
Dog |
Monkey |
Cat |
Rat |
Fox |
Squirrel |
Racoon |
Horse |
Hedgehog |
Bat |
All |
| Number of cases |
62 |
10 |
6 |
2 |
1 |
1 |
1 |
1 |
1 |
1 |
86 |
| Percentage of all cases |
72.1 |
11.6 |
7.0 |
2.3 |
1.2 |
1.2 |
1.2 |
1.2 |
1.2 |
1.2 |
100 |
This growth in tourism is expected to result in more imported cases of
rabies. Pre-exposure rabies vaccination coverage and awareness of rabies
risk in international travellers to rabies-endemic areas, especially those
where rabies prophylaxis facilities are poor, still needs to be improved.
Worldwide, most human deaths from rabies occur in Asia, Africa and South
America. Slovenian travellers were most often potentially exposed in the
popular tourist destination of Croatia, where rabies is enzootic but where
there are well-developed programmes of post-exposure treatment for humans.
There were 633 laboratory-confirmed cases of rabies in animals in Croatia
in 2003 [8], and this situation did not improve substantially in 2004. Cases
of laboratory-confirmed rabies in animals in Slovenia still occur, but after
the introduction of aeroplane-assisted wildlife vaccination, cases in wild
animals dropped from 1089 in 1995 [5] to 8 in 2003 [8].
Rabies is almost 100% vaccine preventable. For pre-exposure and post-exposure
treatment of travellers, only cell culture-prepared rabies vaccine is used
in Slovenia, because it provides a high level of protection and has low
rates of side effects [9-11].