Recent updates on laboratory diagnosis of rabies.

Rabies is a lethal viral disease transmitted through the bite of rabid animals. India has a high burden of rabies, contributing to a significant proportion of the global deaths. However, under-reporting of the disease is prevalent due to lack of laboratory confirmation. Laboratory diagnosis of rabies plays a crucial role in differentiating the disease from clinical mimics, initiation of appropriate care, implementing infection control measures and informing disease surveillance. This review provides an overview of the recent advancements in laboratory diagnosis of rabies, aimed at updating physicians involved in diagnosis and management of rabies cases in India.

Evaluation of the effect of sample suspension concentration and viral load on the outcome of the rabies tissue culture infection test.

In this study, we examined various brain suspension concentrations and viral loads in Neuro-2a cell cultures using 20 rabies-positive bovine samples. The reproducibility of results varied: 65% showed consistent outcomes across all concentrations, while 35% disagreed in at least one. Viral titers ranged from less than 25 × 101 to 25 × 103.50 TCID50/mL, with 20% below 25 × 101 TCID50/mL. Concentrations between 5% and 20% yielded over 90% agreement in positive results, but at 30%, agreement dropped from 85% to 50%. Cell confluence was successfully maintained at 5%, 10%, and 20%, while concentrations of 30% and above led to confluence loss. Low viral loads also negatively impacted reproducibility. These results suggest that sample concentration has a direct influence on preservation of cell confluence and that low viral loads may influence the reproducibility of the rabies tissue culture infection test (RTCIT).

Dog and Cat Bites: Rapid Evidence Review.

Animal bites are a significant burden to health care systems worldwide. In the United States, dog bites account for an average of 337,000 emergency visits and generate medical costs of up to $2 billion per year. Most animal bites in adults and children are from a dog, and most bite patients are children who have been bitten by animals known to them. Dog bites may cause crush and soft-tissue avulsion, whereas cat bites usually cause deeper puncture-type wounds. Children most often present with dog bites on the head and neck, and adolescents and adults usually present with dog bites on the extremities and hands. Bite wounds should be examined, cleaned, and irrigated with warm water or normal saline solution, and any foreign bodies and devitalized tissue should be removed. Neurovascular function (e.g., pulses, sensation) and range and movement of adjacent joints should be examined and documented. Antibiotic prophylaxis, with amoxicillin/clavulanate as the first-line choice, should be considered for all bites, particularly for those at increased risk of infection. Imaging and laboratory studies are usually not required unless there is suspicion of a retained foreign body, damage to underlying structures, infection, or extensive injury. Primary closure of bite wounds may be performed if there is low risk of infection. The need for tetanus vaccination and rabies postexposure prophylaxis should be evaluated for each patient; bites that do not break the skin generally do not require rabies postexposure prophylaxis.

Evaluation of lateral flow devices for postmortem rabies diagnosis in animals in the Philippines: a multicenter study.

Expansion of the use of lateral flow devices (LFD) for animal rabies diagnosis can help mitigate the widespread underreporting of rabies. However, this has been hindered by the limited number and small sample size of previous studies. To overcome this limitation, we conducted a multicenter study with a larger sample size to assess the diagnostic accuracy of the ADTEC LFD for postmortem rabies diagnosis in animals. Thirteen governmental animal diagnostic laboratories in the Philippines were involved in this study, and 791 animals suspected of having rabies were tested using both the direct fluorescence antibody test (DFAT) and ADTEC LFD between August 2021 and October 2022. The LFD demonstrated a sensitivity of 96.3% [95% confidence interval (CI): 94.1%-97.9%] and a specificity of 99.7% (95% CI: 98.4%-100%). Notably, false-negative results were more likely to occur in laboratories with lower annual processing volumes of rabies samples in the previous years (adjusted odds ratio 4.97, 95% CI: 1.49-16.53). In this multicenter study, the high sensitivity and specificity of the LFD for the diagnosis of animal rabies, compared to that of the DFAT, was demonstrated, yet concerns regarding false-negative results remain. In areas with limited experience in processing rabies samples, it is essential to provide comprehensive training and careful attention during implementation.

Case Report: Survival from Clinical Rabies in a Young Child from Maharashtra, India, 2022.

A 3.5-year-old male child from Maharashtra, India, presented with features of meningoencephalitis approximately 1 month after sustaining severe bite injuries on the right hand from a stray dog. He had received four doses of post-exposure intradermal rabies vaccination (on days 0, 3, and 7 of the bite and erroneously on day 20, instead of day 28 as recommended in the updated Thai Red Cross regimen) as well as local and systemic injections of equine rabies immune globulin. The child was initially diagnosed with and treated for acute encephalitis syndrome before rabies encephalitis was confirmed by detection of rabies virus neutralizing antibodies in the cerebrospinal fluid. During the emergent period, he also received the antimalarial drug artesunate, recently reported to have antiviral effects against rabies virus. With intensive and supportive care, the child showed substantial clinical improvement over the next few weeks. He has now survived for more than 10 months after disease onset, albeit with severe neurological sequelae including diffuse cerebral and cerebellar atrophy.

Comparative evaluation of some techniques used for the detection of rabies virus.

Background: Neurotropic viruses in the family Rhabdoviridae, genus Lyssavirus, are what cause rabies, an acute, progressive, and highly lethal encephalomyelitis. Aim: Evaluation of the used diagnostic techniques to determine the most simple; rapid and accurate test for rabies virus (RABV) recognition in different specimens aiming to reach a rapid diagnosis as a step aid in the disease control and to prevent or even minimize the suspected hazard. Method: The used techniques included an infection trial of Swiss mice with the mice-adapted challenge rabies virus followed by the detection of the virus in the infected mices' brains. Virus detection was carried out through the application BHK21 cell line infection; fluorescent antibody technique; latex agglutination test (LAT); direct enzyme-linked immunosorbent assay (ELISA); rabies antigen detection kit ELISA; conventional polymerase chain reaction (PCR). Results: It was found that virus inoculation in mice and BHK21 cell lines needs 5-7 days with positivity of 90% and 100%, respectively. Rapid antigen kit was able to detect rabies antigen in mice brains suspension and BHK21 infected fluid within 3-5 minutes with percentages of 60% and 55.5%, respectively. In 1-1.5 hours, the direct fluorescent antibody method (DFAT) detected 90% and 100% of the rabies antigen in BHK21 cell line infection and brain impressions, respectively. Latex agglutination showed clear results with 88.8% with BHK21 infected fluid within 3-5 minutes while it did not carry out on brain emulsions to prevent falsely positive results brought on by the presence of tissue fragments. Conventional one-step PCR revealed 100% positivity with either brain or cell culture preparations within 2 days. Direct ELISA showed 88.8% positivity with BHK21 infected fluid with 1 day of work. Conclusion: Mice inoculation test, cell culture infection; DFAT and PCR are the most accurate techniques for the detection of RABV with a positivity of 90%-100% followed by LAT and ELISA with a positivity of 88.8%, and lastly, rabies antigen ELISA kit (RAK) with a positivity of 55.5%-60% taking in consideration the required time for each. In addition, the positivity % of the applied tests revealed their sensitivity and specificity.

Evaluation of an iELISA for detection and quantification of rabies antibodies in domestic dog sera.

Many rabies endemic-countries have recognized rabies as a public health problem that can be eliminated. As a result, some countries have started implementing small-scale vaccination programs with the aim of scaling them up. Post-vaccination serological monitoring is crucial to assess the efficacy of these programs. The recommended serological tests, the rapid fluorescent focus inhibition test, and the fluorescent antibody virus neutralization (FAVN) are accurate; however, the procedures require considerable expertise and must be carried out in high containment facilities, which are often not available in rabies endemic countries. Given these constraints, enzyme linked immunosorbent assays (ELISAs) have been considered as alternative methods to neutralization tests. This is the first study to evaluate, under field conditions, the performance of the commercial rabies indirect-ELISA (iELISA), the PlateliaTM Rabies II kit ad usum Veterinarium kit, using sera from domestic dogs. Serum samples were collected from two groups of community dogs in northern Tanzania: i) dogs with no history of vaccination against rabies (n = 100) and ii) dogs vaccinated with the Nobivac Canine Rabies® vaccine (n = 101) four weeks previously. When compared to the gold standard FAVN test, the iELISA was found to be 99% specific and 98% sensitive and there was a significant correlation between the two tests (p < 0.001, r = 0.92). Given these findings, we conclude that the PlateliaTM Rabies II kit ad usum Veterinarium can be considered a valuable tool for the rapid assessment of vaccination status of animals in vaccination programs.

Whole Genome Sequencing for Rapid Characterization of Rabies Virus Using Nanopore Technology.

Genomic data can be used to track the transmission and geographic spread of infectious diseases. However, the sequencing capacity required for genomic surveillance remains limited in many low- and middle-income countries (LMICs), where dog-mediated rabies and/or rabies transmitted by wildlife such as vampire bats pose major public health and economic concerns. We present here a rapid and affordable sample-to-sequence-to-interpretation workflow using nanopore technology. Protocols for sample collection and the diagnosis of rabies are briefly described, followed by details of the optimized whole genome sequencing workflow, including primer design and optimization for multiplex polymerase chain reaction (PCR), a modified, low-cost sequencing library preparation, sequencing with live and offline base calling, genetic lineage designation, and phylogenetic analysis. Implementation of the workflow is demonstrated, and critical steps are highlighted for local deployment, such as pipeline validation, primer optimization, inclusion of negative controls, and the use of publicly available data and genomic tools (GLUE, MADDOG) for classification and placement within regional and global phylogenies. The turnaround time for the workflow is 2-3 days, and the cost ranges from $25 per sample for a 96 sample run to $80 per sample for a 12 sample run. We conclude that setting up rabies virus genomic surveillance in LMICs is feasible and can support progress toward the global goal of zero dog-mediated human rabies deaths by 2030, as well as enhanced monitoring of wildlife rabies spread. Moreover, the platform can be adapted for other pathogens, helping to build a versatile genomic capacity that contributes to epidemic and pandemic preparedness.

Evaluation of a rapid, chip-based, micro-PCR assay for detection of rabies virus in human and canine specimens.

Rabies, a lethal zoonotic encephalitis, remains a significant global health concern, causing an estimated 60 000 annual fatalities worldwide. Dogs serve as the primary reservoirs and vectors for transmitting this infection to humans. Definitive diagnosis of rabies in both human and animal cases necessitates laboratory testing involving various clinical specimens. However, the complexity of laboratory infrastructure and the need for skilled personnel, along with the challenge of maintaining cold-chain integrity during sample referral, hinder the decentralization of diagnostic facilities. This study aimed to assess the efficacy of the Truenat rabies assay, a rapid, portable, semiautomated, and closed PCR-based system, for the diagnosis of rabies in both humans and animals. The Truenat assay demonstrated a sensitivity of 100% and a specificity of 86.96% when compared with the fluorescent antibody test (FAT), as the reference standard, on 147 canine brain samples tested. Notably, the Truenat assay exhibited a sensitivity and specificity of 100% when tested on 48 human brain specimens. Furthermore, an examination of 148 human antemortem samples (cerebrospinal fluid, saliva, and skin biopsy) using both the Truenat assay and a validated real-time reverse transcriptase PCR assay revealed a κ value of 0.505, indicative of a moderate level of agreement between the two tests. Thus, the Truenat assay offers a robust, reliable, and affordable point-of-care solution to enhance rabies diagnostic capacity in endemic areas.

Diagnosis of rabies using reverse-transcription polymerase chain reaction on post-mortem skin tissue specimens of the nasolabial plate in a rabies suspected cow: a case study.

In India, rabies in cattle is under-reported. Religious sentiments hamper its diagnosis, discouraging post-mortem examination, particularly opening the cranium. Specimens of peripheral tissue innervated by the cranial nerves could potentially be used as alternative diagnostic specimens to the brain. Herein, we present a case study of a novel approach for diagnosing rabies in a cow suspected of having rabies, using skin tissue specimens of the nasolabial plate obtained post-mortem. Brain and nasolabial tissue specimens tested positive for rabies using conventional reverse-transcription polymerase chain reaction. This approach has been previously shown to have a high diagnostic sensitivity in animals. We encourage further studies with more nasolabial plate skin specimens for both post- and antemortem diagnosis of rabies in cattle.

Canine rabies: An epidemiological significance, pathogenesis, diagnosis, prevention, and public health issues.

Rabies is a zoonotic disease caused by rabies virus of the genus Lyssa virus and family Rhabdoviridae. It affects all mammals and is prevalent throughout the world and endemic in many countries except in Islands like Australia and Antarctica. It is highly fatal, but preventable. Disease causes threat to public health because rabid dogs bite humans, resulting in thousands of deaths every year. Around 59,000 people die every year from rabies in the world. Dogs play a vital role in most of the human exposure in rabies endemic areas. Transmission of virus occurs through the bite of an infected dog. Disease is manifested by fatal nervous symptoms leading to paralysis and death. Direct fluorescent antibody technique is the gold standard for the diagnosis of the disease in animals and humans. Prevention of rabies involves the vaccination of dogs and humans before or after an exposure. This review describes the etiology, pathogenesis, diagnosis, its prevention and control strategies.

Portable reduced graphene oxide biosensor for detection of rabies virus in bats using nasopharyngeal swab samples.

Rabies is a lethal zoonotic disease caused by rabies virus (RABV) that affects human health and the economy. RABV is transmitted mainly by bats in Brazil, and surveillance in remote areas is hampered by the difficulty of properly collecting samples during fieldwork and the diagnosis is performed in laboratory conditions. Here, we report a portable electrochemical biosensor based on nucleic acid interactions for RABV detection in nasopharyngeal swab samples. The working electrode of the biosensor is composed of reduced graphene oxide (rGO) thin-film immobilized with cDNA through pi-pi stacking to enhance virus detection and specificity. Sensor performance was determined using RNA, and swab samples from bats. RNA detection shows good selectivity, and quantification presents a highly linear calibration curve (R2 = 0.990) using a concentration range of 0.145-25.39 ng/µL. A LOD of 0.104 ng/µL was reached with a sensitivity of 0.321 µA (ng/µL)-1. RABV detection in nasopharyngeal swab samples showed a good difference of positive sample from negative with a response time in seconds, ultra-fast detection compared to known techniques. Three biosensor groups were identified and named after physic-chemical surface characterization as: GO-1, GO-2, and rGO; with best performance for rGO group due to its sp2 hybridized network. Thus, we have successfully fabricated a promising electrochemical biosensor for fast in-situ detection of the RABV in swab samples, which can be expanded to other enveloped viruses that have RNA.

Analysis of available animal testing data to propose peer-derived quantitative thresholds for determining adequate surveillance capacity for rabies.

Historical targets for country-level animal rabies testing volumes were abandoned due to ethical and welfare concerns, and interpretation challenges of testing healthy animals. To-date, no quantitative threshold has been established for evaluating adequate surveillance capacity specific to suspected rabid animals. The purpose here is to establish quantitative testing thresholds for rabies suspected animals to assess a country's rabies surveillance capacity. Animal rabies testing data was obtained from official and unofficial rabies surveillance platforms from 2010 to 2019 and supplemented with official country reports and published literature. Testing rates were determined for all-animal and domestic animals, and standardized per 100,000 estimated human population; the domestic animal rate was also standardized per 100,000 estimated dog population. There were 113 countries that reported surveillance data eligible for analysis. Countries reporting the most data were under WHO categories as having endemic human rabies or no dog rabies. The annual median all-animal testing rate for all countries was 1.53 animals/100,000 human population (IQR 0.27-8.78). Three proposed testing rate thresholds are an all-animal rate of 1.9 animals/100,000 humans, a domestic animal per human rate of 0.8 animals/100,000 humans, and a domestic animal per dog rate of 6.6 animals/100,000 dogs. These three peer-derived rabies testing thresholds for passive surveillance can be used to facilitate assessment of a country's rabies surveillance capacity.

Comparison of Pan-Lyssavirus RT-PCRs and Development of an Improved Protocol for Surveillance of Non-RABV Lyssaviruses.

Rabies is a zoonotic and fatal encephalitis caused by members of the Lyssavirus genus. Among them, the most relevant species is Lyssavirus rabies, which is estimated to cause 60,000 human and most mammal rabies deaths annually worldwide. Nevertheless, all lyssaviruses can invariably cause rabies, and therefore their impact on animal and public health should not be neglected. For accurate and reliable surveillance, diagnosis should rely on broad-spectrum tests able to detect all known lyssaviruses, including the most divergent ones. In the present study, we evaluated four different pan-lyssavirus protocols widely used at an international level, including two real-time RT-PCR assays (namely LN34 and JW12/N165-146), a hemi-nested RT-PCR and a one-step RT-PCR. Additionally, an improved version of the LN34 assay ((n) LN34) was developed to increase primer-template complementarity with respect to all lyssavirus species. All protocols were evaluated in silico, and their performance was compared in vitro employing 18 lyssavirus RNAs (encompassing 15 species). The (n) LN34 assay showed enhanced sensitivity in detecting most lyssavirus species, with limits of detection ranging from 10 to 100 RNA copies/µL depending on the strain, while retaining high sensitivity against Lyssavirus rabies. The development of this protocol represents a step forward towards improved surveillance of the entire Lyssavirus genus.

[Lethal cases of lyssavirus encephalitis in humans after contact with bats in the Russian Far East in 2019-2021].

INTRODUCTION: On the territory of Russia four species of lyssaviruses (genus Lyssavirus) were identified, three of them caused human deaths. THE AIM OF WORK: to characterize fatal cases in humans after contacts with bats in the Far East in 20182021 and to perform typing of isolated pathogens. MATERIALS AND METHODS: Lyssavirus infection was confirmed in samples of sectional material from people who died in the Amur Region in 2019, in the Primorsky Krai in 2019 and 2021. Diagnostics was performed by fluorescent antibody test (FAT) and RT-PCR using diagnostic kits of domestic production. Viruses were isolated in a bioassay. The nucleoprotein sequences were analyzed after 1st passage. The analysis of phylogenetic relationships and the construction of a dendrogram were performed using the MEGA7 software. RESULTS: The viruses that caused the fatal cases in humans in the Amur Region and Primorsky Krai share more than 90% identity to Lyssavirus irkut detected in Russia and China. Together they form a separate monophyletic cluster with 100% bootstrap support. CONCLUSION: On the territory of Russia, monitoring of bat populations for infection with lyssaviruses is relevant. The material of people who died from encephalomyelitis of unknown etiology within 1015 days from the onset of the disease must be examined for lyssavirus infection. It is necessary to develop PCR assays that employ genus-specific primers. The use of molecular biological methods is promising for improving the diagnosis of rabies and epidemiological surveillance, as well as increasing the efficiency of the system of biological safety of the population of the Russian Federation.

Molecular Analysis of Rabies Virus Using RNA Extracted from Used Lateral Flow Devices.

Molecular analysis of rabies virus can provide accurate diagnosis and information on its genetic diversity. The transportation of rabies brain samples from remote areas to a central laboratory is challenging owing to biohazard risks and decomposability. We investigated the utility of used lateral flow devices (LFDs) for subsequent molecular analysis and assessed the necessary storage temperatures. Using RNA extracted from used LFD strips, we performed conventional reverse transcription-PCR (RT-PCR) using an LN34 primer set to amplify short fragments (165 bp) for rabies virus detection and the P1-304 primer set to amplify long fragments of the entire N gene amplicon (1,506 bp) for phylogenetic analysis. Among 71 used LFDs stored in a refrigerator and 64 used LFDs stored at room temperature, the LN34 assay showed high sensitivities (96.2% and 100%, respectively) for the diagnosis of rabies, regardless of the storage temperature. A significant reduction in the sensitivity of rabies diagnosis was observed when using the P1-304 primer set for used LFDs stored at room temperature compared to those stored at refrigeration temperature (20.9% versus 100%; P < 0.05). Subsequent sequencing and phylogenetic analysis were successfully performed using the amplicons generated by the P1-304 RT-PCR assays. Used LFDs are thus promising resources for rabies virus RNA detection and sequence analysis. Virus detection via RT-PCR, amplifying a short fragment, was possible regardless of the storage temperature of the used LFDs. However, refrigerated storage is recommended for RT-PCR amplification of long fragments for phylogenetic analysis.

Diagnostic sensitivity and specificity of immunohistochemistry for the detection of rabies virus in domestic and wild animals in South Africa.

We estimated the diagnostic sensitivity (DSe) and specificity (DSp) of an immunohistochemistry (IHC) protocol compared to the direct fluorescent antibody test (DFAT), which is the gold standard test for rabies diagnosis. We obtained brain samples from 199 domestic and wild animal cases (100 DFAT-negative, 99 DFAT-positive), by convenience sampling from 2 government-accredited rabies virus (RABV) testing laboratories in South Africa, between February 2015 and August 2017. Tissues that had been stored at 4-8°C for several days to weeks at the 2 accredited laboratories were formalin-fixed and paraffin-embedded. Nighty-eight cases tested IHC-positive using a polyclonal anti-RABV nucleoprotein antibody and a polymer detection system. The overall DSe and DSp for the RABV IHC test were 98% (95% CI: 93-100%) and 99% (95% CI: 95-100%), respectively. Domestic dogs accounted for 41 of 98 RABV IHC-positive cases, with the remainder in 4 domestic cats, 25 livestock, and 28 wildlife. Herpestidae species, including 7 meerkats and 9 other mongoose species, were the most frequently infected wild carnivores, followed by 11 jackals. Three cases in domestic dogs had discordant test results; 2 cases were IHC-/DFAT+ and 1 case was IHC+/DFAT-. Considering the implications of a false-negative rabies diagnosis, participating in regular inter-laboratory comparisons is vital, and a secondary or confirmatory method, such as IHC, should be performed on all submitted specimens, particularly negative cases with human contact history.

From Field Tests to Molecular Tools-Evaluating Diagnostic Tests to Improve Rabies Surveillance in Namibia.

Rabies is endemic in Namibia and is present both in wildlife carnivores and domestic free-roaming dogs. The disease thus represents a challenge for public human and veterinary disease control. Namibia has implemented a national strategic plan to control rabies and the country's activities are supported by international organizations. To this end, rabies diagnosis at the Central Veterinary Laboratory (CVL) was improved in the frame of a World Organization for Animal Health (WOAH) laboratory twinning program: from practical sampling techniques and the use of lateral flow devices to a novel universal and discriminatory quantitative real-time Reverse transcription polymerase chain reaction (RT-qPCR), which easily identify dog-associated rabies viruses. The procedures applied and the results can be used as a template to improve rabies laboratory diagnosis.