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Ongoing rabies outbreak in dogs of unprecedented scale and human cases in Nelson Mandela Bay Municipality, South Africa, up to 13 February 2022
More than 430 cases of rabies have been confirmed in dogs in the Nelson Mandela Bay Metropolitan Municipality of South Africa since July 2021. We describe the ongoing outbreak, its geographical spread and six related human deaths that have occurred. Further investigation of the outbreak and vaccination of the dog population is required. Raising awareness among healthcare providers, the public, and among international travellers planning to visit the region, is key for action to protect human and animal health.
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Abandon of intramuscular administration of rabies immunoglobulin for post-exposure prophylaxis in the revised guidelines in the Netherlands in 2018: cost and volume savings
The World Health Organization (WHO) issued an updated position paper on rabies in 2018, mainly focusing on simplification of vaccination schedules and use of rabies immunoglobulin (RIG). The maximum amount of RIG anatomically feasible should be infiltrated exclusively in and around the wound and will no longer be calculated solely based on body weight. We describe the practical guideline implementing the revised RIG policy in the Netherlands on how to determine the amount of RIG for local administration. We calculated savings achieved through the revised WHO policy. We used information from a national database including rabies consultations in the Netherlands and clinical information from a public health service, clinical practitioners and national data on the amount of distributed RIG. Between 2008 and 2019, 5,164 consultations were registered. The most frequently affected anatomical location was hand or leg (43%). Around 80% concerned minor injuries (< 2 cm). From January 2016 to end December 2019, 7,361 mL RIG were distributed for 1,042 possible rabies exposures (EUR 1.4 million). Since implementing the revised policy, the amount of RIG distributed per order has sharply decreased (59%). Infiltrating RIG only locally saved large quantities of human RIG (EUR 1.1 million during 4 years) in the Netherlands.
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Prevention of human rabies: a challenge for the European Union and the European Economic Area
Rabies is enzootic in over one hundred countries worldwide. In the European Union/European Economic Area (EU/EEA), the vast majority of human rabies cases are travellers bitten by dogs in rabies-enzootic countries, mostly in Asia and Africa. Thus, EU/EEA travellers visiting rabies enzootic countries should be aware of the risk of being infected with the rabies virus when having physical contact with mammals. They should consider pre-exposure vaccination following criteria recommended by the World Health Organization and if unvaccinated, immediately seek medical attention in case of bites or scratches from mammals. As the majority of the EU/EEA countries are free from rabies in mammals, elimination of the disease (no enzootic circulation of the virus and low number of imported cases) has been achieved by 2020. However, illegal import of potentially infected animals, mainly dogs, poses a risk to public health and might threaten the elimination goal. Additionally, newly recognised bat lyssaviruses represent a potential emerging threat as the rabies vaccine may not confer protective immunity. To support preparedness activities in EU/EEA countries, guidance for the assessment and the management of the public health risk related to rabies but also other lyssaviruses, should be developed.
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Rabies vaccination strategies in the Netherlands in 2018: a cost evaluation
BackgroundThe risk of contracting rabies is low for travellers. However, the number of Dutch travellers potentially exposed abroad following an animal-associated injury and needing post-exposure prophylaxis (PEP) has increased, resulting in increased costs.
AimHere, we evaluated the costs and the cost-effectiveness of different pre- and post-exposure interventions in the Netherlands, taking into account the 2018 World Health Organization (WHO) recommendations for the prevention of rabies.
MethodsA decision tree-based economic model was constructed. We calculated and compared the cost of different WHO pre-exposure prophylaxis (PrEP) recommendations, intramuscular vs intradermal vaccination and PEP subsequent to increased vaccination coverage in risk groups. We estimated cost-effectiveness, expressed as incremental costs per rabies immunoglobulin (RIG) administration averted, using a societal perspective. Statistical uncertainty regarding number of travellers and vaccination coverage was assessed.
ResultsTotal costs at the national level were highest using previous WHO recommendations from 2012, estimated at EUR 15.4 million annually. Intradermal vaccinations in combination with the current recommendations led to the lowest costs, estimated at EUR 10.3 million. Higher vaccination uptake resulted in higher overall costs. The incremental costs per RIG administration averted varied from EUR 21,300-46,800.
ConclusionsThe change in rabies PrEP and PEP recommendations in 2018 reduced total costs. Strategies with increased pre-travel vaccination uptake led to fewer RIG administrations and fewer vaccinations after exposure but also to higher total costs. Although larger scale intradermal administration of rabies vaccine can reduce total costs of PrEP and can positively influence vaccination uptake, it remains a costly intervention.
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The shift in rabies epidemiology in France: time to adjust rabies post-exposure risk assessment
The epidemiology of rabies in France and western Europe has changed during the past 22 years. In France, rabies in non-flying terrestrial mammals was declared to be eliminated in 2001, and the risk of rabies is now limited to contact with bats, rabid animals illegally imported from rabies-enzootic countries and traveller exposure in enzootic areas. We analysed the epidemiology of rabies in France from 1995 to 2016, describing and analysing data on human rabies surveillance as well as data on post-exposure prophylaxis (PEP) collected from the network of French antirabies clinics. Over the study period, seven individuals were diagnosed with rabies in France, all of whom were infected outside mainland France. PEP data analysis revealed an expected overall decrease in PEP administration for individuals exposed in mainland France, but there was still overuse of anti-rabies drugs, given the very low epidemiological risk. On the other hand, a significant increase in PEP delivered to individuals exposed abroad was evidenced. These epidemiological trends indicate that clear guidelines should be provided to support physicians’ efforts to adjust rabies risk assessment to the evolution of the epidemiological situation.
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The One Health approach for the management of an imported case of rabies in mainland Spain in 2013
A C Pérez de Diego , M Vigo , J Monsalve and A EscuderoAfter more than 30 years without any reported cases of rabies in terrestrial carnivores in mainland Spain, an imported case was detected in June 2013 in Toledo. Although the infected dog was moved across different locations and had contact with humans and dogs, the incident was controlled within a few days. An epidemiological investigation was performed and rabies-free status in terrestrial carnivores in mainland Spain was restored six months after the incident. Key to the successful management of this case were the previous vaccination of susceptible animals in the affected area before the case was detected, the collaboration of different authorities in decision making, and the application of control measures according to national and international regulations and to the One Health concept.
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Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 – March 2013
S Tsiodras , G Dougas , A Baka , C Billinis , S Doudounakis , A Balaska , T Georgakopoulou , G Rigakos , V Kontos , K E Tasioudi , M Tzani , P Tsarouxa , P Iliadou , O Mangana-Vougiouka , D Iliopoulos , S Sapounas , P Efstathiou , A Tsakris , C Hadjichristodoulou and J KremastinouGreece has been rabies-free since 1987 with no human cases since 1970. During 2012 to 2013, rabies has re-emerged in wild and domestic animals in northern Greece. By end March 2013, rabies was diagnosed in 17 animals including 14 red foxes, two shepherd dogs and one cat; 104 subsequent human exposures required post-exposure prophylaxis according to the World Health Organization criteria. Human exposures occurred within 50 km radius of a confirmed rabies case in a wild or domestic animal, and most frequently stray dogs were involved.
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Fatal case of human rabies imported to Italy from India highlights the importance of adequate post-exposure prophylaxis, October 2011
P De Benedictis , G Perboni , C Gentili , L Gaetti , F Zaffanella , F Mutinelli , I Capua and G CattoliIn October 2011, an Indian man resident in Italy was admitted to a hospital in Mantua, Italy with symptoms of acute encephalitis. Due to a recent history of bite by a suspected rabid dog in India, where he had received incomplete post-exposure treatment, rabies was suspected. The patient died after 22 days of intensive care treatment and rabies was confirmed post mortem. This report stresses the need of appropriate post-exposure prophylaxis in rabies-endemic countries.
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Fatal case of imported human rabies in Amadora, Portugal, August 2011
More LessWe report on a case of imported human rabies in Portugal, in July 2011 in a woman who presented initially complaining of back pain, without relating exposure to animal bites. She had travelled from Portugal to Bissau, Guinea-Bissau, in April where she had been bitten by a dog on 1 May. She was diagnosed with rabies on 26 July and died two weeks later in spite of being treated following the Milwaukee protocol.
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Public health implications of an outbreak of rabies in arctic foxes and reindeer in the Svalbard archipelago, Norway, September 2011
E MacDonald , K Handeland , H Blystad , M Bergsaker , M Fladberg , B Gjerset , O Nilsen , H Os , S Sandbu , E Stokke , L Vold , I Ørpetveit , H Gaup Åmot and O TveitenBetween 16 September and 5 October 2011 rabies was diagnosed in two arctic foxes and eight reindeer in the Svalbard archipelago, in Norway. This outbreak occurs at the end of the reindeer hunting season and poses an increased risk to many people that were involved in the hunt. As of 28 September 2011, 280 people had received post-exposure prophylaxis. No human cases of rabies have occurred.
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Rabid dog illegally imported to France from Morocco, August 2011
A Mailles , D Boisseleau , L Dacheux , C Michalewiscz , C Gloaguen , N Ponçon , H Bourhy , H Callon , V Vaillant , I Dabosville and P Morineau-Le HoussineIn August 2011, a case of canine rabies was notified to the French veterinary services. The dog was a three-month-old puppy illegally imported from Morocco that presented behavioural changes on 1 August and was admitted to a veterinary clinic on 6 August. It died the following day and the body was shortly sent to the national reference centre where rabies was laboratory-confirmed on 11 August. Contact tracing and post-exposure treatment were initiated immediately.
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Rabies in an Arctic fox on the Svalbard archipelago, Norway, January 2011
I Ørpetveit , B Ytrehus , T Vikøren , K Handeland , A Mjøs , S Nissen , H Blystad and A LundWe report a case of rabies in an Arctic fox. In January 2011 a fox attacked dogs belonging to a meteorological station in the Svalbard archipelago, Norway. Rabies virus was detected in the fox's brain post-mortem. The dogs had been vaccinated against rabies and their antibody levels were protective. Post-exposure prophylaxis was administered to staff at the station. Rabies vaccination is recommended for inhabitants and visitors to the Arctic who may be in contact with wild animals.
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Impact of emergency oral rabies vaccination of foxes in northeastern Italy, 28 December 2009–20 January 2010: preliminary evaluation
K Capello , P Mulatti , A Comin , L Gagliazzo , V Guberti , C Citterio , P De Benedictis , M Lorenzetto , C Costanzi , P Vio , P Zambotto , G Ferri , F Mutinelli , L Bonfanti and S MarangonFox rabies re-emerged in northeastern Italy in 2008, in an area bordering Slovenia. In 2009, the infection spread westward to Veneto region and in 2010 to the provinces of Trento and Bolzano. Aerial emergency oral fox vaccination was implemented in the winter 2009-10. Since this vaccination was performed at altitudes below the freezing level, a statistical analysis was conducted to evaluate its impact. Of the foxes sampled following the vaccination campaign, 77% showed a rabies antibody titre of ≥0.5 IU/ml.
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Is there a need for anti-rabies vaccine and immunoglobulins rationing in Europe?
More LessRabies is a lethal encephalitis caused by a lyssavirus and transmitted from animals to humans via bite wound, scratch wound, or licking of mucous membranes. It is preventable by timely administration of post-exposure prophylaxis (PEP) consisting of four or five doses of rabies vaccine combined, in the most severe cases of exposures, with anti-rabies immunoglobulin (RIG). Although the rabies incidence in humans remains low, rabies is still present in some European countries. Moreover, rabid animals imported from enzootic areas are reported every year in rabies-free areas. These importations threaten the rabies-free status of terrestrial animals in western European countries and challenge the public health surveillance system and the health structures responsible for rabies prophylaxis and control. The importations frequently result in the prescription of a large number of PEP including RIG, especially in western European countries. The situation is inverted in some central and eastern European countries where RIG is underprescribed. Only a limited number of rabies vaccines and particularly of RIG are licensed for use in Europe. Their availability is also limited, a situation that may become worse in the future. It therefore seems important to study the possibility of comparing and unifying national PEP guidelines in Europe, if needed, and to generate effective solutions in the event of a shortage of anti-rabies biological products and RIG in particular, such as rationing these products.
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A human case of travel-related rabies in Austria, September 2004
A young male Austrian tourist, aged 23 years and unvaccinated against rabies, was bitten by a dog in Morocco in July 2004. One month later he was hospitalised in Ceuta with symptoms compatible with rabies. He died on 23 September in an Austrian hospital after a diagnosis of rabies was confirmed by FAT, IHC and RT-PCR (including sequencing) of the neck skin and the RT-PCR (including sequencing) of the pharyngeal swab. This Austrian case of laboratory confirmed rabies highlights the urgent need for reinforcement of the international recommendations for travel vaccinations.
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