Meeting the urgent need for rabies education in Haiti.

The highest rate of human rabies deaths reported in the Americas is in Haiti, and most of these deaths result from rabies virus infections that occur after individuals are bitten by infected dogs and do not receive rabies post-exposure prophylaxis. One barrier to rabies prevention in Haiti is a lack of knowledge about this disease among healthcare professionals and community members. During the past 4 years, The US Centers for Disease Control and Prevention has collaborated with public health officials and partners to develop, test and refine educational materials aimed at filling this need for rabies education. This report summarizes the use of feedback from knowledge, attitudes and practises surveys; key informant interviews; and focus groups to develop culturally appropriate rabies prevention materials for community members, health officials, clinicians, laboratory professionals, veterinary professionals, government officials and national and local district leaders about ways to prevent rabies. These formative research methods were critically important in ensuring that the materials would be culturally appropriate and would stand the greatest likelihood of motivating Haitians to protect themselves from rabies. Centers for Disease Control and Prevention is using lessons learned in Haiti to develop and test materials in other countries with high rates of canine rabies.

Rabies diagnosis and surveillance in animals in the era of rabies elimination.

Effective real-time surveillance, combined with proficient, decentralised and validated laboratory diagnostics, is a prerequisite for successful rabies control and elimination. The selection and prioritisation of surveillance methodologies, in conjunction with appropriate diagnostic techniques, should reflect the goals of the disease control and elimination programme (Stage 1: proof of burden; Stage 2: human rabies prevention; Stage 3: monitoring and assessment of control measures; Stage 4: verification of rabies elimination; and Stage 5: post elimination). The development of minimum surveillance requirements, in accordance with Chapter 1.4 of the World Organisation for Animal Health Terrestrial Animal Health Code, and routine evaluation of disease elimination indicators are of the utmost importance if the goal of eliminating dog-mediated human rabies by 2030 is to be achieved.

Une surveillance efficace en temps réel soutenue par des tests diagnostiques performants et validés réalisés par des laboratoires décentralisés est une condition préalable pour que les efforts de contrôle et d'élimination de la rage soient couronnés de succès. Le choix et la priorisation des méthodes de surveillance et des techniques diagnostiques qui leur sont associées doivent tenir compte des objectifs du programme de lutte et d'élimination de la rage (phase 1 : détermination de la charge induite par la maladie ; phase 2 : prévention de la rage humaine ; phase 3 : suivi et évaluation des mesures de lutte ; phase 4 : vérification de l'absence de rage ; phase 5 : post-élimination). Il est essentiel d'élaborer des mesures minimales de surveillance en conformité avec les dispositions du chapitre 1.4. du Code sanitaire pour les animaux terrestres de l'Organisation mondiale de la santé animale et de procéder à une évaluation systématique des indicateurs de l'élimination de la maladie si l'on veut atteindre l'objectif de l'élimination de la rage humaine transmise par les chiens d'ici 2030.

Para que las actividades de control y eliminación de la rabia culminen con éxito es requisito previo e indispensable una vigilancia eficaz en tiempo real, combinada con una labor competente y descentralizada de diagnósticos de laboratorio validados. La selección y jerarquización de los métodos de vigilancia, junto con el uso de técnicas apropiadas de diagnóstico, deben responder a los objetivos marcados en el programa de control y eliminación de la enfermedad (fase 1: datos demostrativos de la carga de enfermedad; fase 2: prevención de la rabia humana; fase 3: seguimiento y evaluación de las medidas de control; fase 4: verificación de la eliminación de la rabia; y fase 5: periodo posterior a la eliminación). La definición de requisitos mínimos de vigilancia, de conformidad con el capítulo 1.4. del Código Sanitario para los Animales Terrestres de la Organización Mundial de Sanidad Animal (OIE), así como la evaluación sistemática de indicadores relativos a la eliminación de la enfermedad, revisten la mayor importancia para que se cumpla el objetivo de haber eliminado la rabia transmitida por perros para 2030.

Production and calibration of the second batch of OIE anti-rabies positive reference serum.

The Biological Standards Commission of the World Organisation for Animal Health (OIE) oversees the preparation and validation of OIE-approved International Reference Standards for use in serological assays for detecting infectious diseases of animals or the adequacy of their immune response following vaccination against those diseases. The principal use of OIE-approved International Reference Standards is to harmonise serological testing and to promote the mutual recognition of test results for international trade. In the OIE Manual of Diagnostic Tests and Vaccines for Terrestrial Animals, the organisation recommends the use of the OIE anti-rabies positive reference serum of dog origin to titrate serum samples in international units (IU)/ml for use in rabies serological tests. The first batch of OIE reference serum of dog origin was produced in1991 and was used internationally until the beginning of 2010. The preparation of the new batch began in 2012 and, in contrast to the previous batch, three commercial inactivated rabies vaccines based on the most frequently used vaccine strains (Pasteur Virus and Flury Low Egg Passage) were selected for the immunisation of dogs in accordance with OIE guidelines. In 2013, calibration was completed through an inter-laboratory test involving five OIE Reference Laboratories for Rabies with the Second World Health Organization (WHO) International Standard for Anti-Rabies Immunoglobulin being used as a reference standard in this calibration. After statistical analysis of the results, the consensus titre was established as 5.59 IU/ml. The technical and statistical data were submitted to the OIE for assessment. In February 2014, the OIE Biological Standards Commission adopted this serum as an OIE-approved standard reagent for rabies serology.

La Commission des normes biologiques de l'Organisation mondiale de la santé animale (OIE) supervise la préparation et la validation de réactifs internationaux de référence approuvés par l'OIE et destinés aux épreuves sérologiques ayant pour objet le diagnostic des maladies infectieuses des animaux ou le suivi de l'effet protecteur obtenu par la vaccination contre ces maladies. Les réactifs internationaux de référence approuvés par l'OIE sont principalement utilisés pour harmoniser les tests sérologiques et permettre la reconnaissance mutuelle des résultats des tests dans le cadre des échanges internationaux. Le Manuel des tests de diagnostic et des vaccins pour les animaux terrestres de l'OIE recommande d'utiliser le sérum de référence antirabique positif d'origine canine de l'OIE pour exprimer le titre des échantillons de sérum analysés en unités internationales (UI)/ml lors des épreuves sérologiques. Le premier lot de sérum de référence d'origine canine de l'OIE, produit en 1991, a été utilisé à l'échelle internationale jusqu'au début de l'année 2010. La préparation d'un nouveau lot a commencé en 2012 et, contrairement au lot précédent, trois vaccins antirabiques inactivés disponibles dans le commerce, basés sur les souches vaccinales les plus utilisées dans le monde (souche Pasteur et souche Flury Low Egg Passage) ont été choisis pour l'immunisation des chiens, conformément aux lignes directrices de l'OIE. L'étalonnage s'est achevé en 2013 lors d'un essai inter-laboratoires auquel ont participé cinq Laboratoires de référence de l'OIE pour la rage ; le second étalon international pour l'immunoglobuline antirabique de l'Organisation mondiale de la santé (OMS) a été utilisé en tant que réactif de référence pour cet étalonnage. Après analyse statistique des résultats, le titre consensuel obtenu est de 5,59 UI/ml. Les données techniques et statistiques ont été soumises à l'OIE pour évaluation. En février 2014, la Commission des normes biologiques de l'OIE a adopté ce sérum en tant qu'étalon de référence approuvé par l'OIE pour la sérologie de la rage.

La Comisión de Normas Biológicas de la Organización Mundial de Sanidad Animal (OIE) supervisa la preparación y validación de patrones de referencia internacional aprobados por la OIE para su utilización en ensayos serológicos destinados a detectar enfermedades animales infecciosas o a valorar la idoneidad de la respuesta inmunitaria de un animal al ser vacunado contra una u otra enfermedad. Dichos patrones sirven sobre todo para armonizar la realización de pruebas serológicas y promover el reconocimiento mutuo de los resultados de las pruebas con fines de comercio internacional. En su Manual de las Pruebas de Diagnóstico y de las Vacunas para los Animales Terrestres, la OIE recomienda el empleo del suero positivo antirrábico de referencia de la OIE, de origen canino, para titular muestras de suero en unidades internacionales (UI)/ml y utilizarlas en pruebas serológicas de detección de la rabia. El primer lote de suero de referencia de la OIE procedente de perros fue elaborado en 1991 y estuvo en uso a nivel internacional hasta principios de 2010. La preparación del nuevo lote dio comienzo en 2012 y, a diferencia del lote anterior, para la inmunización del perro se seleccionaron tres vacunas inactivadas comerciales basadas en las cepas vacunales utilizadas con más frecuencia (virus Pasteur y cepa Flury Low Egg Passage), de conformidad con las directrices de la OIE. En 2013 culminó el proceso de calibración con una prueba interlaboratorios en la que intervinieron cinco Laboratorios de Referencia de la OIE para la rabia. En esta calibración se utilizó como patrón de referencia el segundo patrón internacional de inmunoglobulina antirrábica de la Organización Mundial de la Salud (OMS). Tras el análisis estadístico de los resultados, el título de consenso quedó fijado en 5,59 UI/ml. Los datos técnicos y estadísticos fueron sometidos a la valoración de la OIE, cuya Comisión de Normas Biológicas, en febrero de 2014, aprobó este suero como reactivo de referencia aprobado por la OIE para pruebas serológicas de detección de la rabia.

Clinical management and humoral immune responses to rabies post-exposure prophylaxis among three patients who received solid organs from a donor with rabies.

BACKGROUND: The rabies virus causes a fatal encephalitis and can be transmitted through organ transplantation. In 2013, a man developed rabies 18 months after receiving a kidney from a donor with rabies, who was not known to have been infected when the organs were procured. Three additional persons who received organs from the same donor (liver, kidney, heart), all of whom were not vaccinated for rabies before transplantation, received rabies post-exposure prophylaxis (PEP) with rabies immune globulin and 5 doses of rabies vaccine as soon as the diagnosis of rabies was made in the donor (18 months after their transplant surgeries). We describe their clinical management. METHODS: As the 3 recipients were all on immunosuppressive medications, post-vaccination serologic testing was performed using the rapid fluorescent focus inhibition test to measure rabies virus neutralizing antibodies (RVNAs). An acceptable antibody response to administration of rabies vaccine was defined as detection of RVNAs at a concentration ≥0.1 IU/mL from a serum specimen collected ≥7 days after the fifth vaccine dose. RESULTS: All 3 recipients demonstrated an acceptable antibody response despite their immunosuppressed states. More than 36 months have passed since their transplant surgeries, and all 3 recipients have no evidence of rabies. CONCLUSIONS: The survival of 3 previously unvaccinated recipients of solid organs from a donor with rabies is unexpected. Although the precise factors that led to their survival remain unclear, our data suggest that PEP can possibly enhance transplant safety in settings in which donors are retrospectively diagnosed with rabies.

Oral vaccination and protection of striped skunks (Mephitis mephitis) against rabies using ONRAB®.

Skunks are one of the most important rabies vector species in North America due to their wide geographic distribution, high susceptibility to the rabies virus, and tendency to inhabit areas around human dwellings and domestic animals. Oral vaccination is a cost-effective, socially acceptable technique often used to control rabies in terrestrial wildlife; however, control of rabies in skunks has proven especially challenging due to the lack of a vaccine effective by the oral route in this species. In this study, we examined the antibody response of captive striped skunks (Mephitis mephitis) to ONRAB(®) and tested the protection afforded by the vaccine against rabies virus. Thirty-one skunks were each offered one ONRAB(®) vaccine bait, 25 skunks were administered ONRAB(®) via direct instillation into the oral cavity (DIOC) and ten controls received no vaccine. A blood sample was collected from controls and vaccinates 6 weeks prior to treatment, and then 5 and 7 weeks post-vaccination (PV). A competitive ELISA was used to detect rabies antibody (RAb). Pre-vaccination sera for all skunks, and sera for all controls throughout the serology study, were negative for RAb. Fifty-eight percent (18/31) of skunks in the bait group and 100% (25/25) of skunks that received ONRAB(®) DIOC had detectable RAb by 7 week PV. All 10 controls succumbed to experimental rabies infection. In the group of skunks administered ONRAB(®) DIOC, 100% (23/23) survived challenge 247 days PV. Survival of skunks presented ONRAB(®) baits was 81% (25/31). In the bait group, all 18 skunks that had detectable RAb by 7 week PV survived challenge. Seven additional skunks without detectable RAb prior to week 7 PV also survived. Lack of any remarkable pathology in study animals, together with positive serology and challenge results, supports that ONRAB(®) is a safe and effective oral rabies vaccine for use in skunks.

A large-scale, rapid public health response to rabies in an organ recipient and the previously undiagnosed organ donor.

This article describes and contrasts the public health response to two human rabies cases: one organ recipient diagnosed within days of symptom onset and the transplant donor who was diagnosed 18 months post-symptom onset. In response to an organ-transplant-related rabies case diagnosed in 2013, organ donor and recipient investigations were conducted by multiple public health agencies. Persons with potential exposure to infectious patient materials were assessed for rabies virus exposure. An exposure investigation was conducted to determine the source of the organ donor's infection. Over 100 persons from more than 20 agencies spent over 2700 h conducting contact investigations in healthcare, military and community settings. The 564 persons assessed include 417 healthcare workers [5.8% recommended for post-exposure prophylaxis (PEP)], 96 community contacts (15.6% recommended for PEP), 30 autopsy personnel (50% recommended for PEP), and 21 other persons (4.8% recommended for PEP). Donor contacts represented 188 assessed with 20.2% recommended for PEP, compared with 5.6% of 306 recipient contacts recommended for PEP. Human rabies cases result in substantial use of public health and medical resources, especially when diagnosis is delayed. Although rare, clinicians should consider rabies in cases of encephalitis of unexplained aetiology, particularly for cases that may result in organ donation.

Trends in nosocomial bloodstream infections in a burn intensive care unit: an eight-year survey.

This study was designed to evaluate the frequency and profile of bloodstream infection (BSI) in a burn intensive care unit (BICU) in Tripoli, Libya, from 1st January 2000 to 31st December 2007 and to determine the prevalence of different bacteria involved in such infections and their antimicrobial susceptibilities. During the eight-year study period, 995 patients were admitted to the BICU. Blood cultures were collected from each septicaemic case and reviewed for age, sex, total body surface area burned, isolated micro-organisms, and antibiotic sensitivity. There were 430 episodes of BSI among 830 cases; the annual true positive rate varied between 40.0 and 59.4%, the majority (87.9%) being caused by one species only. However, 22% had two or more episodes with different pathogens during hospitalization. The leading isolate was Staphylococcusaureus (40.4%) (methicillinresistant, 55.7%). Pseudomonas spp ranked second (23.9%). Klebsiella spp were third, responsible for 7.4%; the rate of extended spectrum beta lactamase among Klebsiella isolates was 47%. Candida spp were the fourth most common pathogen (6.7%), the majority (55%) being C. albicans. Staphylococci were generally resistant to trimethoprim (91%) and fusidic acid (80%). Pseudomonas spp proved moderately resistant (38-43%) to tobramicin, ciprofloxacin, amikacin, and impenem but remained relatively susceptible to cefepime (72%). Klebsiella isolates demonstrated moderate resistance (46-58%) to most agents tested, and relatively low resistance (19-27%) to meropenem, impenem, and cefepime. We suggest that extra infection control measures should be implemented and antibiotic policy and guidelines introduced to reduce the high resistance rate among isolates such as Pseudomonas, Acinetobacter, and MRSA.

Enhancing comparative rabies DNA vaccine effectiveness through glycoprotein gene modifications.

Enhancing DNA vaccine effectiveness remains a challenge, especially if the desired goal is immunization efficacy after a single dose. The glycoprotein gene from the rabies virus Evelyn-Rokitnicki-Abelseth (ERA) strain was modified by mutation at amino acid residue 333 from arginine to glutamine. The modified and original unmodified glycoprotein genes were cloned separately and developed as DNA vaccines for immunization in mice. The intramuscular (IM) route using a single dose (100 microg) of a modified DNA vaccine showed virus neutralizing antibody induction by d30, and 80% of the mice survived a challenge in which 100% of unvaccinated controls succumbed. Similar results were obtained using a single dose (10 microg) by the intradermal (ID) route with one-tenth amount of the DNA administered. Administration of single dose of DNA vaccine with unmodified G did not result in the production of detectable levels of virus neutralizing antibody by d30. The results of the IM and the ID routes of administration were statistically significant (P<0.01). Based on these preliminary results, a modified glycoprotein gene from the ERA rabies virus strain may be an ideal candidate for DNA vaccine efficacy enhancement.

Detection of high levels of European bat lyssavirus type-1 viral RNA in the thyroid gland of experimentally-infected Eptesicus fuscus bats.

Two common bat lyssavirus species have been identified in many European countries: European bat lyssavirus type-1 and -2 (EBLV-1 and EBLV-2). Only limited knowledge on the susceptibility of the natural EBLV-hosts, insectivorous bats, to lyssavirus infection is available. Our study was undertaken to evaluate the susceptibility and pathology associated with an EBLV-1 infection in Eptesicus fuscus following different routes of virus inoculation including intracranial (n = 6), intramuscular (n = 14), oral (n = 7) and intranasal (n = 7). Blood and saliva samples were collected from all bats on a monthly basis. Four bats inoculated intracranially developed rabies with a mean of 11 days to death, whilst seven bats inoculated intramuscularly developed rabies, with an extended incubation period prior to death. We did not observe any mortality in the oral (p.o.) or intranasal (i.n.) groups and both groups had detectable levels of virus neutralizing antibodies (data not shown). Virus shedding was demonstrated in the saliva by virus isolation and the detection of viral RNA in ill bats, particularly immediately prior to the development of disease. In addition, the presence of virus and viral RNA was detected in the thyroid gland in bats challenged experimentally with EBLV-1, which exceeded that detected in all other extra-neural tissue. The significance of detecting EBLV-1 in the thyroid gland of rabid bats is not well understood. We speculate that the infection of the thyroid gland may cause subacute thyroiditis, a transient form of thyroiditis causing hyperthyroidism, resulting in changes in adrenocortical activity that could lead to hormonal dysfunction, thereby distinguishing the clinical presentation of rabies in the rabid host.

Experimental infection of big brown bats (Eptesicus fuscus) with West Caucasian bat virus (WCBV).

Big brown bats (Eptesicus fuscus), either recently captured individuals or survivors from previous experimental infection with Irkut virus (IRKV), were inoculated with West Caucasian bat virus (WCBV), intramuscularly into the masseter (n=7) or neck (n=8) muscles, or orally (n=6). Three bats inoculated into the neck muscles developed rabies and died between days 10 and 18. Viral RNA was detected in a number of tissues but isolation was successful only from the brain. An oral swab of one of these bats was also PCR-positive, but the isolation attempt failed. Brains, salivary glands and swabs from the survivors (six months observation) were negative, as well as all blood pellets collected. Therefore, no suggestions for a carrier state or viremia were obtained. In four surviving bats inoculated in the masseter muscles, WCBV-neutralizing antibodies were detected up to the end of experiment. The absence of antibodies in the three rabid bats may be the result of shorter incubation periods. Bats infected orally neither died nor responded serologically. In the bats previously infected with IRKV, IRKV-neutralizing antibodies were detected as well, up to the end of observation (12 months after IRKV challenge), even if they were not boosted by WCBV inoculation.

Susceptibility of North American big brown bats (Eptesicus fuscus) to infection with European bat lyssavirus type 1.

The aim of this study was to determine the susceptibility of insectivorous bats (using the big brown bat as a model) to infection with European bat lyssavirus type 1a (EBLV-1a), to assess the dynamics of host immune responses and to evaluate the opportunity for horizontal viral transmission within colonies. Two isolates of EBLV-1a, originating from Slovakia (EBLV-1aSK) and Germany (EBLV-1aGE), were tested. Four different routes of inoculation were used with isolate EBLV-1aSK [10(4.8) mouse intracerebral median lethal dose (MICLD(50)) in 50 mul]: intramuscular (i.m.) in the deltoid area or masseter region, per os (p.o.) and intradermal (i.d.) scratches. Isolate EBLV-1aGE (10(3.2) and 10(2.2) MICLD(50) in 20 mul) was inoculated via the intranasal (i.n.), i.m. (low- and high-dose groups, into pectoral muscles); p.o. and intracerebral (i.c.) routes. None of the bats infected by the i.n., p.o. or i.d. route with either virus isolate developed disease during the experiments (91 or 120 days, respectively). Incubation periods were 9-12 days for i.c.-inoculated bats (66 % mortality), 12-33 days for bats inoculated i.m. with the higher dose (23-50 % mortality) and 21-58 days in bats inoculated i.m. with the lower dose of virus (57 % mortality). Virus or viral RNA in bat saliva was detected occasionally, as early as 37 days before death. All i.d.-inoculated and the majority of i.m.-inoculated bats seroconverted within 7-10 days of inoculation. These observations suggest that exposure of bats to varying doses of EBLV-1 from rabid conspecifics via natural (i.d.) routes could lead to an abortive infection and serve as a natural mode of immunization resulting in the presence of virus-neutralizing antibodies in free-ranging bats.