Epidemiologic Aspects of Animal Bite, Rabies, and Predictors of Delay in Post-exposure Prophylaxis: A National Registry-based Study in Iran.

BACKGROUND: The increasing trend in animal bites and rabies in recent years makes the disease a public health concern in Iran. The objectives of the current study were to investigate the epidemiologic aspects of the animal bite and determine the associated risk factors of the delay in initiation of post-exposure prophylaxis (PEP) against rabies in Iran. STUDY DESIGN: National registry-based cross-sectional study. METHODS: This study included all registered cases of animal bites between March 2021 and March 2022 at the Ministry of Health and Medical Education in Iran. We retrieved epidemiologic data on person, time, place, and PEP outcome. RESULTS: A total of 260470 animal bite cases (approximately 334 per 100000 populations, and 11 deaths) were registered during the study period. About 77.2% of them were reported in males, 4.3% in children aged less than 5 years, 56.4% occurred in urban areas, 98% in domestic animals, and mostly in north and northeast areas of Iran. Additionally, 2.8% of cases had a delay of more than 48 hours in the initiation of PEP. Significant determinants of the increase in delay were female gender (OR=1.43, 95% CI: 1.36, 1.51, P<0.001), foreign nationality (OR=1.19, 95% CI: 1.01, 1.12, P=0.001), rural residence (OR=1.07, 95% CI: 1.01, 1.12, P=0.010), and the wild animals (OR=1.22, 95% CI: 1.12, 1.34, P<0.001). CONCLUSION: The observed frequency of animal bites in a year indicates a serious public health concern and the need for targeted interventions, especially in at-risk areas and vulnerable populations.

Large scale dog population demography, dog management and bite risk factors analysis: A crucial step towards rabies control in Cambodia.

Cambodia is a rabid-endemic country. However, data on dog population characteristics are lacking, and there is no national dog vaccination program. We implemented the first extensive door-to-door longitudinal survey in 2 Cambodian provinces, namely Kandal and Battambang, to estimate dog population demographic parameters, identify dog ownership determinants, analyze dog management practices and estimate the yearly cumulative bite incidence and associated factors. During the first session, more than 5000 dogs were recorded and identified. Data on families, dogs and cats characteristics, as well as the number of bites experienced the year before in the family, were recorded. One year later, a second session was performed in both provinces to record missing dogs and the reasons for missing. Age-specific survival rates of the dog populations were computed using Kaplan-Meier estimates. Ownership determinants and bite risk factors were identified using a negative binomial regression model. Dog trade and dog meat consumption were often reported. We estimated high dog-to-human ratios (1:3.8 in Kandal, and 1:3.3 in Battambang). The mean age of dog populations was 26.4 months in Kandal against 24.3 in Battambang, with a survival rate of 52% at 24 months in Kandal (34% only in Battambang). They were no feral dogs, but the large majority of recorded dogs were free roaming. In both provinces, the number of dogs significantly increased in families with children younger than 15, and when the head of the family was a male. The estimated yearly cumulative bite incidences were 2.3 and 3.1% in Kandal and Battambang provinces respectively, and are among the highest in the world. Our survey provides valuable data to focus information programs, parametrize transmission models and identify efficient vaccination strategies to control rabies in Cambodia in the future.

Rabies post-exposure healthcare-seeking behaviors and perceptions: Results from a knowledge, attitudes, and practices survey, Uganda, 2013.

BACKGROUND: Rabies is a viral disease of animals and people causing fatal encephalomyelitis if left untreated. Although effective pre- and post-exposure vaccines exist, they are not widely available in many endemic countries within Africa. Since many individuals in these countries remain at risk of infection, post-exposure healthcare-seeking behaviors are crucial in preventing infection and warrant examination. METHODOLOGY: A rabies knowledge, attitudes, and practices survey was conducted at 24 geographically diverse sites in Uganda during 2013 to capture information on knowledge concerning the disease, response to potential exposure events, and vaccination practices. Characteristics of the surveyed population and of the canine-bite victim sub-population were described. Post-exposure healthcare-seeking behaviors of canine-bite victims were examined and compared to the related healthcare-seeking attitudes of non-bite victim respondents. Wealth scores were calculated for each household, rabies knowledge was scored for each non-bitten survey respondent, and rabies exposure risk was scored for each bite victim. Logistic regression was used to determine the independent associations between different variables and healthcare-seeking behaviors among canine-bite victims as well as attitudes of non-bitten study respondents. RESULTS: A total of 798 households were interviewed, capturing 100 canine-bite victims and a bite incidence of 2.3 per 100 person-years. Over half of bite victims actively sought medical treatment (56%), though very few received rabies post-exposure prophylaxis (3%). Bite victims who did not know or report the closest location where PEP could be received were less likely to seek medical care (p = 0.05). Respondents who did not report having been bitten by a dog with higher knowledge scores were more likely to respond that they would both seek medical care (p = 0.00) and receive PEP (p = 0.06) after a potential rabies exposure event. CONCLUSIONS: There was varying discordance between what respondents who did not report having been bitten by a dog said they would do if bitten by a dog when compared to the behaviors exhibited by canine-bite victims captured in the KAP survey. Bite victims seldom elected to wash their wound or receive PEP. Having lower rabies knowledge was a barrier to theoretically seeking care and receiving PEP among not bitten respondents, indicating a need for effective and robust educational programs in the country.

Epidemiology of human rabies in South Africa, 2008 - 2018.

BACKGROUND: Human rabies cases continue to be reported annually in South Africa (SA). Previous investigations have shown the association between the occurrence of human rabies cases and dog rabies cases in the country. OBJECTIVES: To describe the epidemiology of laboratory-confirmed human rabies cases in SA for the period 2008 - 2018. METHODS: A retrospective document review of laboratory-confirmed human rabies cases for the period 2008 - 2018 was performed using a case register and related documentation available from the National Institute for Communicable Diseases. RESULTS: A total of 105 human rabies cases were laboratory confirmed from 2008 to 2018, with cases reported from all the provinces of SA except the Western Cape. Children and adolescents were most affected by the disease during the study period. In almost half of the cases, medical intervention was not sought after exposure. When victims did seek healthcare, deviations from post-exposure prophylaxis protocols were reported in some cases. CONCLUSIONS: The epidemiological trends of human rabies cases reported in SA for the period 2008 - 2018 remained largely the same as in previous reports. Dog-mediated rabies remains the main source of human rabies in SA.

Risk factors for rabies in Côte d'Ivoire.

Rabies affects more than 150 countries worldwide. Côte d'Ivoire is one of the rabies-endemic countries that has recorded deaths every year since 2006. The evolution of these deaths is almost constant with an average of 18 annual deaths (annual incidence = 0.06-0.08 per 100,000). Children predominate among these victims. However, prevention measures exist in anti-rabies centers distributed throughout the country. The objective of this study was to determine the factors related to rabies risk in Côte d'Ivoire through Gavi rabies project entitled 'Impact of rabies and immunization in Central and West Africa'. The implementation was conducted from 2016 to 2018 in two departments of Côte d'Ivoire (Bouake and San Pedro). The study population was dog-bite victims vaccinated in anti-rabies centers of project sites from January to December 2016. Two non-free rabies immunization protocols are used in the country (Essen and Zagreb). Information was collected from bites victims for an adequate follow-up. It was to apprciate the risk of developing rabies through access to care, the immunization status of biting animal, the category of exposure and the result of rabies post exposure prophylaxis (compliance). Local program implementers responsible for these bite-management activities and veterinary staff had receved training and the necessary material. The public health education and information dissemination activities were carried out in support of promoting a wide spread of rabies prevention messages. Household surveys were conducted by sociology students in 4002 households each in urban and in rural areas. This activity helped to find people exposed by dogs and who did not receive any Post Exposure Prophylaxis (PEP). The study registered 1,263 bite victims in pilot anti-rabies centers in 2016, 51% of them were children. People living in urban areas were strongly represented (87%) because of anti-rabies centers proximity. Dog was the most animal associated to exposure (94%). Seventy-two percent (72%) of them had owners, but only 14% were vaccinated against rabies. More than half of dog bite victims had category III of exposure (58%). PEP compliance record was very low (37%), which means that 63% of bite victims have not completed the protocol. This study conducted in Bouaké and San Pedro showed somes factors responsible for rabies deaths evolution in Côte d'Ivoire. Main issues identified are the geographical accessibility of anti-rabies centers, frequent bites caused by unvaccinated dogs, often category III of exposure and many non-completions of rabies PEP in ignorance context. The establishment of national comprehensive and integrated rabies control program is needed in Côte d'Ivoire. It must take into account all these factors by focusing on public awareness, dog vaccination and adoption of modern intradermal vaccination regimens to better manage rabies situation in Côte d'Ivoire.

Epidemiological study on animal bite cases referred to Haji Daii health Center in Kermanshah province, Iran during 2013-2017.

BACKGROUND: Over thousands of animal bite cases are reported annually worldwide and in Iran placing a large financial burden on the health and economy. The aim of this study was to evaluate the epidemiology of animal bite cases in Kermanshah, Iran through 2013-2017. METHODS: In this cross-sectional study, 5618 animal bite cases in Kermanshah from 2013 to 2017 were studied. Data were analyzed using descriptive and inferential statistics. RESULTS: In the study period, 5618 animal bite cases were found. The prevalence of animal bites was estimated between 42.55-45.66 per100000 populations during 2013-2017. An increasing significant trend was found for prevalence of animal bites (Average annual percent change [AAPC] + 4.9, P-trend< 0.001) over a 5-years' time period. The mean age of the subjects was 32.7 ± 18.3 years. Of the studied subjects 76.3% were male, and 34% had non-governmental jobs. Dogs were found as the cause of animal bites in 72% of the cases. Of the studied cases, 82% had received rabies vaccination for three times. CONCLUSION: The results showed an increasing significant trend for animal bites in Kermanshah. Development of interventional programs, such as limiting stray dogs, vaccination of dogs and raising public awareness are essential.

Identification of risk factors for rabies exposure and access to post-exposure prophylaxis in Chad.

Rabies remains a global public health problem, with Africa as one of the most affected continents. Endemic transmission in the unvaccinated domestic dog population of developing countries leads to many exposures with subsequent death in humans due to lack of access to existing effective prevention tools. The presented study identifies factors of exposure and rabies risk in Chad on the household and health facility levels and highlights the challenges of access to Post Exposure Prophylaxis (PEP). Data on bite exposure and prevention was collected through a representative cross-sectional survey in rural and urban households and through a continuous bite reporting survey in public health facilities. During the household survey 8000 homes were visited, including 3241 (41%) in urban areas and 4759 (59%) in rural areas. The frequency of dog ownership was similar in both rural and urban areas, with around 24% households owning at least one dog. Knowledge of rabies as a disease transmitted mainly from dogs to humans was generally good, but higher in urban (86%) compared to rural areas (73%). The need for early prevention and medical care after a bite was less well known with 35% of respondents believing that rabies is curable after onset of symptoms and only one in three bite victims seeking help in a health facility. Exposure risk based on bite incidence on the population level was increased for Christian compared to Muslim predominant religious context. During the health facility study, 1540 bite cases were registered, of which 58% originated from urban areas and 42% from rural areas. Demographic characteristics of the health facility data subset matched the household survey data subset for the majority of parameters. Only bites from known animals (same household or from neighbourhood) and bites from animals known to be alive were underrepresented, suggesting that such bites are regarded as less dangerous than bites from unknown animals and animals that died, were killed or disappeared. Since human vaccine was provided free of charge during the study, most victims received PEP (84%). However, not all patients completed treatment, with a higher risk of non-compliance observed in rural areas. Access to vaccine before the study was alarmingly low, with only 8.5% accessing PEP. Despite facilitated collaboration between human health and veterinary services through the project, consultation with veterinary services remained generally low. The observed challenges can inform future rabies control programmes on the national level to effectively increase access to PEP exceeding the expected improved availability of human vaccine through the upcoming GAVI investment.

Population- and Variant-Based Genome Analyses of Viruses from Vaccine-Derived Rabies Cases Demonstrate Product Specific Clusters and Unique Patterns.

Rabies in wildlife has been successfully controlled in parts of Europe and North America using oral rabies vaccination, i.e., the distribution of baits containing live-attenuated virus strains. Occasionally, these vaccines caused vaccine virus-induced rabies cases. To elucidate the mechanisms of genetic selection and the effect of viral populations on these rabies cases, a next generation sequencing approach as well as comprehensive data analyses of the genetic diversity of Street Alabama Dufferin (SAD) and ERA vaccine virus strains and vaccine-induced rabies cases from Canada and several European countries were conducted. As a result, twelve newly generated sets of sequencing data from Canada and Poland were added to a pool of previously investigated samples. While the population-based analysis showed a segregation of viruses of ERA vaccine-induced rabies cases from those of SAD Bern original (SAD Bernorig)-derived rabies cases, the in-depth variant analysis revealed three distinct combinations of selected variants for the ERA vaccine-induced cases, suggesting the presence of multiple replication-competent haplotypes in the investigated ERA-BHK21 vaccine. Our findings demonstrate the potential of a deep sequencing approach in combination with comprehensive analyses on the consensus, population, and variant level.

Animal bites and rabies post-exposure prophylaxis, active and reserve components, U.S. Armed Forces, 2011-2018.

During 2011-2018, there were 22,729 diagnoses of animal bites among active and reserve component members of the U.S. Armed Forces. Of these, 899 (4.0%) were documented during medical encounters associated with deployments to overseas theaters of operations. Army, Navy, Air Force, and Marine Corps members were affected by 55.6%, 23.5%, 14.2%, and 6.7% of all animal bites diagnosed in theater, respectively. More than four-fifths of total animal bite cases (82.4%) and bites diagnosed in theater (88.4%) affected enlisted members. The crude overall incidence rate of animal bite diagnoses was 175.7 per 100,000 person-years (p-yrs) among active component service members between 2011 and 2018. Overall rates were highest among active component service members who worked in law enforcement (462.5 per 100,000 p-yrs) or veterinary occupations (437.8 per 100,000 p-yrs). Among active component service members, the crude annual rate of animal bite diagnoses in 2018 was more than twice that in 2001 (194.1 per 100,000 p-yrs and 85.1 per 100,000 p-yrs, respectively). Dog bites accounted for approximately three-quarters (74.8%) of total animal bites during the surveillance period. Only a small proportion of animal bites were associated with documentation of exposure to or post-exposure prophylaxis for rabies. Animal bite avoidance and rabies education should be reinforced before service members travel or deploy to areas where rabies is highly enzootic.

Risk Factors and Spatio-Temporal Patterns of Human Rabies Exposure in Northwestern Tigray, Ethiopia.

BACKGROUND: Rabies is a neglected tropical disease, which is economically important with great public health concerns in developing countries including Ethiopia. Epidemiological information can play an important role in the control and prevention of rabies, though little is known about the status of the disease in many settings of Ethiopia. The present study aimed to investigate the risk factors and spatio-temporal patterns of human rabies exposure in Northwestern Tigray, Ethiopia. METHODS: A prospective study was conducted from 01 January 2016 to 31 December 2016 (lapsed for one year) at Suhul general hospital, Northern Ethiopia. Data of human rabies exposure cases were collected using a pretested questionnaire that was prepared for individuals dog bite victims. Moreover, GPS coordinate of each exposure site was collected for spatio-temporal analysis using hand-held Garmin 64 GPS apparatus. Later, cluster of human rabies exposures were identified using Getis-Ord Gi* statistics. RESULTS: In total, 368 human rabies exposure cases were collected during the study year. Age group of 5 to 14 years old were highly exposed (43.2%; 95% CI, 38.2-48.3). Greater number of human rabies exposures was registered in males (63%; 95% CI, 58.0-67.8) than females (37%; 95% CI, 32.1-42.0). Residents of rural (85.6%; 95% CI, 81.6-88.8) areas were at greater risk to rabies than urban residents (14.4%; 95% CI, 11.2-18.4). Higher proportion of human rabies exposures were caused by unprovoked (96.5%; 95% CI, 94.0-98.0) and unvaccinated (85.9%; 95% CI, 81.9-89.1) dogs. All rabies exposures were exclusively caused by dog bites and the majority of them (80.4%; 95% CI, 76.0-84.2) were caused by stray dogs. Results of spatio-temporal analysis showed that Asgede Tsimbla, Endaselassie and Laelay Adiyabo districts experienced the highest burden of rabies exposure; identified as hot spots. Strong peaks of human rabies exposure occurred between March and July months. CONCLUSION: The present study provided basic epidemiological information on the potential risk factors associated with human rabies exposure. Moreover, our findings provided basis for understanding the spatio-temporal patterns of human rabies in Northwestern Tigray districts for the first time.

Clinical features of rabies patients with abnormal sexual behaviors as the presenting manifestations: a case report and literature review.

BACKGROUND: Abnormal sexual behaviors presenting as manifestations of rabies have occasionally been reported in the literature, although little attention has been paid to these cases to date. This study aimed to analyze the clinical features of rabies cases with abnormal sexual behaviors as the presenting manifestations. CASE PRESENTATION: A case of 32-year-old man with frequent ejaculation as the initial symptom of rabies was first reported. Then, a literature review was conducted using databases including CNKI, SinoMed, VIP, Wanfang Data, ScienceDirect, ProQuest, OVID and PubMed. In addition to our case, 54 other rabies cases, with abnormal sexual behaviors as the presenting manifestations, have been reported since 1970. Among the 55 cases, 51 were male and three were female (unknown gender for one case), with ages ranging from 6 to 71 years. All cases were reported in developing countries, 46 in China. Dog bites were the major source of infection, and extremities were the main exposure sites. Overall, 46 (83.6%) cases had abnormal sexual behaviors as the initial symptoms. The major presenting manifestations were priapism and ejaculation in males and hypersexuality in females. All cases were clinically diagnosed based on medical history and clinical manifestations. Given no standardized post-exposure prophylaxis, all cases died with the survival time being between 1 and 15 days. CONCLUSIONS: The rabies patients with abnormal sexual behaviors have unique clinical features. To avoid misdiagnosis, unexplained abnormal sexual behaviors should raise clinical suspicion of rabies.

Vaccine-associated rabies in red fox, Hungary.

Rabies vaccine strain was isolated from a red fox (Vulpes vulpes) with signs of neurological disorder during an oral vaccination campaign in 2015, Hungary. The whole genome sequence of the isolated strain shared >99.9% nucleotide sequence identity to the whole genomes of vaccines strains recently used in Hungarian oral vaccination campaigns. The neuroinvasive potential of rabies vaccines that leads to development of clinical manifestations is rarely seen among wild animals; however, the observed residual pathogenicity needs awareness of field experts and requires close monitoring of rabies cases in areas where elimination programs are implemented.

Characteristics and factors associated with post-exposure prophylaxis (PEP) treatment of dog and cat bites among left-behind children: a cross-sectional study in two cities of China.

OBJECTIVE: Animal injury is a significant cause of morbidity and mortality worldwide. Dog bites account for tens of millions of injuries annually and the highest risk is among children. However, children may not receive postexposure prophylaxis (PEP) treatment timely and appropriately after rabies exposure. This study aimed to investigate the characteristics and factors associated with PEP treatment of dog and cat bites among left-behind children. DESIGN: A cross-sectional study using questionnaire was conducted in primary and high schools. SETTING: Shenzhen and Shantou cities, Guangdong Province, China. PARTICIPANTS: A total of 9380 participants were included and 2236 of them were with a history of dog and cat bites. RESULTS: 1188 (53.1%) boys and 1048 (46.9%) girls suffered from animal bites. Bitten in holidays was less likely to receive PEP treatment (OR 0.512, 95% CI 0.377 to 0.695) than those bitten in school days. Bitten while being with family (OR 1.418, 95% CI 1.040 to 1.934) and bitten at roadside (OR 1.842, 95% CI 1.297 to 2.171), bitten by unvaccinated animals (OR 1.745, 95% CI 1.246 to 2.443) tended to receive PEP treatment. Compared with unbroken skin, bleeding (OR 1.789, 95% CI 1.165 to 2.745) and laceration (OR 3.834, 95% CI 2.310 to 6.366) were showed as treatment prompting factors. CONCLUSIONS: Bitten in holidays was found as a risk factor of receiving PEP treatment of animal bites. Certain measures should be taken to raise left-behind children's awareness of receiving PEP treatment timely and appropriately after dog and cat bites.

Knowledge, attitudes and practices (KAP) towards rabies and free roaming dogs (FRD) in Panchkula district of north India: A cross-sectional study of urban residents.

Canine rabies is endemic in urban India. A questionnaire was administered to 204 residents of the urbanised municipality of Panchkula in north India to assess the influence of gender, age, family size, social status and dog ownership, over the knowledge, attitudes and practices (KAP) towards rabies control and free-roaming dogs (FRD) in their locality. Bivariate analyses revealed significant knowledge gaps regarding crucial information on the control and transmission of rabies. Multivariable logistic regression models found that the respondents with a high/middle socio-economic status were likely to be more knowledgeable than those from low socio-economic levels (OR 3.03, 95%CI 1.5-6.0, p = 0.001). Households with children ≤14 years of age were likely to be lacking in knowledge about rabies compared to households with older or no children (OR 0.5, 95%CI 0.3-0.9, p = 0.04). The attitudes and practices of the respondents towards rabies control was positive in households with a high/middle socio-economic status (OR 3.4, 95%CI 1.7-7.2, p = 0.0008) but poor in older (≥ 35 years) participants (OR 0.4, 95%CI 0.2-0.7, p = 0.001). It is concluded that rabies awareness campaigns should be developed and conducted to target sectors of the urban community such as those belonging to lower socio-economic sections and schools to improve the residents' knowledge and practices towards rabies. Educating dog owners about sterilising their pets is also recommended to alter the attitudes of the residents towards FRD population control.

Knowledge, attitudes and practices (KAP) towards rabies and free-roaming dogs (FRD) in Shirsuphal village in western India: A community based cross-sectional study.

The lack of awareness about dog-bite related rabies in the rural population of developing countries, including India, is a major impediment to controlling the incidence of disease in humans. A survey of 127 rural residents was undertaken in Shirsuphal village in western India using a structured questionnaire to assess the influence of demographic and pet/livestock owning characteristics on the knowledge, attitudes and practices of the respondents towards rabies and free roaming dogs (FRD). Multivariable logistic regression models were constructed and the knowledge of the rural residents of Shirsuphal village was found to be significantly influenced by family size (OR 2.1, 95%CI 1.0-4.6, p = 0.04) and poultry ownership (OR 2.3, 95%CI 1.1-4.9, p = 0.03), while their attitudes towards FRD was significantly influenced by age of the respondents (OR 2.6, 95% CI 1.2-5.8) and ownership of cattle/buffalo (OR 2.2, 95% CI 1.1-5.5). Although the knowledge score about rabies was high, a comprehensive understanding of the disease was lacking. Concerted efforts to widen the knowledge about rabies and promote healthier practices towards FRD are recommended.

Knowledge, attitudes and practices towards dog-bite related rabies in para-medical staff at rural primary health centres in Baramati, western India.

The lack of awareness regarding rabies amongst rural primary care health staff and their adverse practices towards the management of dog-bite wounds is a major contributor to the high incidence of rabies infection and subsequent human mortality in India. A Knowledge, Attitudes and Practices survey was carried out involving 54 nursing and non-nursing staff working in 18 rural Primary Health centres and sub-centres around Baramati town of Pune district in Western India. Multivariable logistic regression models were constructed to assess factors that influenced knowledge of rabies and practices towards management of dog-bite related wounds. The more experienced and better-educated workers were found to have a good awareness of rabies (OR 3.4, 95%CI 1.0-12.1) and good practices towards dog-bite wound management (OR 5.6, 95%CI 1.2-27.0). Surprisingly, non-nursing staff were significantly more knowledgeable about rabies (OR 3.5, 95%CI 1.0-12.3), but their practices towards dog-bite wound management were inadequate (OR 0.18, 95%CI 0.04-0.8) compared to the nursing staff. It is recommended that a mandatory training module for primary care health staff be developed and implemented to improve their knowledge regarding rabies and management of dog-bite wounds to reduce the incidence of human rabies in rural India.