Is there a need for anti-rabies vaccine and immunoglobulins rationing in Europe?

Rabies 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.

Epidemiology and prophylaxis of rabies in humans in France: evaluation and perspectives of a twenty-five year surveillance programme.

The National Reference Centre for Rabies (NRC) was created at the Pasteur Institute after the fox epizootic reached the French territory. The missions of the NRC include, among others, the surveillance of rabies cases in humans and rabies post-exposure prophylaxis (PEP) treatments. The surveillance has been effective since 1982. A Bulletin on the Epidemiology and the Prophylaxis of Rabies in Humans in France is published every year. This Bulletin is now available on the Internet for Human Health and Veterinary national and local Authorities. Since 2005, data is collected with new software, Voozanoo, directly via the Internet. Twenty cases of rabies in humans have been reported since 1970. There were no indigenously acquired cases. The number of PEP treatments peaked in 1990, when the number of cases in the wild fauna was at its acme. Following the decrease of rabies cases in the wild fauna, PEP decreased by 60%. Nevertheless, about4,000 PEP treatments are still carried out. These patients have been exposed to bats or to rabid animals illegally introduced onto the French territory, or during a stay in rabies enzootic countries, or to unobservable animals. The study of this database leads to a number of conclusions: canine variants acquired directly in canine enzootic areas, that are translocated, or acquired through iatrogenic exposure, are responsible for the majority of cases; bats appear to be an increasing source of exposure; PEP surveillance is of utmost importance to monitor and to improve the quality of case management.

[Rabies is a risk for travelling children]. / Le risque de rage chez l'enfant qui voyage.

Rabies remains a dreadful disease which kills about 50,000 people per year, mostly in Asia, Africa, South America and Central Europe. Between 30% an 50% of the victims are young children. Modern rabies vaccines are safe and immunogenic. Therefore parents must be informed on the risk of rabies, and pre-exposure vaccination must be performed for children traveling often or for periods longer than one month in canine enzootic countries. Post-exposure treatment must be initiated without delay with modern vaccines wherever available, according to approved schedules. Pre-exposure vaccination is particularly useful in remote places where modern vaccines and immunoglobulins are not readily available.

[Human rabies in France in 2004: update and management]. / La rage humaine en France en 2004: état des lieux et prise en charge.

Twenty people died of rabies in France between 1970 and 2003 (compared to 55,000 yearly worldwide), 80% on returning from Africa. Dogs were the contaminating animals in 90% of the cases and children were the most common victims. The last instance of rabies in a native French animal was reported in 1998. However the illegal importation of animals still poses a risk. The disease is transmitted by saliva, even before the appearance of clinical symptoms, through a bite, scratch, or licks of mucous membranes or broken skin. Person-to-person transmission has only been observed in cases of grafts (cornea). The mean incubation time of 1 to 3 months is long enough to allow passive immunization and vaccination. After its onset, the disease presents as encephalitis or a paralytic syndrome the outcome of which is always fatal. Clinical diagnosis may be difficult in the early stages of the disease. If rabies is suspected, the National Reference Centre is responsible for the sampling and proper transportation of these samples so as to ensure assessment results within 5 days. If stringent hygiene rules are complied to, there is no risk of contamination for those in close contact. Vaccination, which is performed in official rabies centers, is only performed after a diagnosis based on laboratory evidence, and solely for exposed persons or those for whom a reliable history cannot be established (children under 6 years). Prevention is based on information. People traveling abroad, particularly to Africa, are warned not to approach unknown animals (especially dogs) nor to try to import them, and are advised to comply with vaccinal recommendations for travelers, particularly for toddlers.

Human rabies prophylactics: the French experience.

In 1968, fox rabies was introduced on the French territory, in the Moselle department and from that time, spread southwards and westwards from the French-German border at the speed of 40 km per year. Consequently, a program aimed at controlling and eradicating the disease was carried out. Collaboration between human and veterinary medicine has been the key of the success of this program. In 2001, rabies in terrestrial animals was eradicated from France, while no indigenous human rabies case had been reported. Meanwhile, post-exposure treatments (PET) had been closely monitored. Data on rabies cases in animals, rabies cases in humans, PET, surveillance of exposures to baits and oral vaccines for the wild fauna, and exposures outside the French territory will be successively considered and discussed.

[A case of pulmonary hemosiderosis associated with rhumatoid arthritis with LE cells (author's transl)]. / Hémosidérose pulmonaire associée à une arthrite rhumatoide avec cellules LE.

In a three and a half old girl, we have noticed the apparition: first, of on idiopathic pulmonary hemosiderosis; then, five months later, of a rheumatoid arthritis with LE cells and antinuclear antibodies of very difficult detection. The meaning of this articular involvement is discussed: rheumatoid arthritis with LE cells, or rheumatoid arthritis marking the beginning of a systemic lupud erythematosus. The literature concerning the association of an hemosiderosis and a connectivite is reviewed.