Current status of rabies and prospects for elimination

Rabies encephalitis and extra-neural manifestations in a patient bitten by a domestic cat

Rabies encephalitis is a fatal zoonotic viral disease transmitted to humans either by domestic animals like dogs and cats or by wild animals like bats, skunks and raccoons. We present the case of a 25-year-old woman admitted due to behavioral disorders, generalized paresthesiasand acute respiratory deterioration compatible with a respiratory distress syndrome (ARDS) requiring orotracheal intubation, mechanical ventilation and empirical initiation of antibiotic and antiviral therapy. Chest tomography showed pneumomediastinum and changes suggestive of pulmonary infection. In the presence of neurological symptoms, a central nervous system (CNS) infection was suspected and the cerebrospinal fluid showed no pleocytosis, hiperproteinorrachy without glucose consumption; cranial CT scan was normal. During hospitalization, the family reported that the patient was bitten by a cat 30-day prior to the onset of rabies-like symptoms, and the animal was sacrificed. The patient had an unfavorable clinical evolution, with electroencephalographic activity dissociation evidenced by video telemetry. The zoonotic exposure led to the suspected diagnosis of rabies infection. The patient died and the suspected diagnosis was confirmed by histopathology, with presence of Negri bodies on cerebellum Purkinje cells and a positive immunofluorescence test for rabies virus. Both, initial extra-neural manifestations and late reporting of rabies exposure led to delayed diagnosis.

Implementation of a mass canine rabies vaccination campaign in both rural and urban regions in southern Malawi

Rabies is a devastating zoonotic disease causing nearly 60,000 deaths globally each year. The disease causes Malawi an economic loss of 13 million USD and kills almost 500 people annually. Domestic dogs are the main reservoir for rabies and vaccinating over 70% of the dog population is the most efficient method to reduce its incidence in both humans and canines. However, achieving such coverages is often difficult and depend on many geospatial factors. Rural and pastoral regions are considered difficult to vaccinate efficiently due to low dog densities, and reports of campaigns spanning large areas containing vastly different communities are lacking. This study describes a mass canine vaccination campaign covering rural and urban regions in southern Malawi. The campaign achieved an average vaccination coverage of 83.4% across 3 districts, and vaccinated over 89,000 dogs through a combined static point and door-to-door effort. A dog population of 107,574 dogs was estimated (dog:human ratio of 1:23). The canine population was found to be almost completely owned (99.2%) and mostly kept for security purposes (82.7%). The dogs were mainly adults, males, and not neutered. Regression analysis identified education level and proportion of young dogs as the only factors influencing (positively and negatively, respectively) whether vaccination coverage over 70% was achieved in a region, independently of variables such as population density or poverty. A second regression analysis was performed predicting absolute vaccination coverage. While education level and the proportion of confined dogs were associated with positive vaccination coverage, higher proportions of young animals and female dogs were associated with a decrease in coverage. This study confirms the feasibility of homogeneously vaccinating over 70% of the dogs in a large area including rural and urban communities. These findings can inform the logistics of future campaigns and might be used as a template to facilitate high-number, high-coverage vaccination campaigns to other regions in sub-Saharan Africa.

Common Myths and Legends of Rabies

Humankind has somewhat of a dark, yet almost fascinating, supernatural relationship with rabies. Even after Pasteur's rabies vaccine discovery, globally people continue to be stricken with it today. History has carried along the myths and legends that surround this diabolical virus. Some still believe that rabies treatment requires 20 or more shots to the stomach by some monstrously long needle. However, today's treatment regimen is typically only four vaccinations (five for immunocompromised) in the arm, plus human rabies immune globulin. This chapter explores the misunderstood concepts of rabies prevalence, signs and symptoms, exposures, and treatment protocols.

The immunosuppressed traveler: infection risks with autoimmunity and immunosuppression, vaccinations, and general travel advice

The travel-related infection risks in the significantly immunocompromised traveler are complex and comprise vaccine preventable, vector-borne, and other nonvaccine preventable infections. A thorough risk assessment should be performed before travel and advice sought from relevant specialists. Immunosuppression used to treat autoimmune diseases and their mechanisms of action need particular consideration.This risk assessment needs to take the patient's beliefs and preferences into account. It is also important not to neglect noninfectious travel considerations.

Development of a high number, high coverage dog rabies vaccination programme in Sri Lanka

BACKGROUND

Rabies is estimated to cause 59,000 deaths and economic losses of US$8.6 billion every year. Despite several years of rabies surveillance and awareness programmes, increased availability of post-exposure prophylaxis vaccinations and dog population control, the disease still remains prevalent in Sri Lanka. This study reports the roll-out of a high number, high coverage canine rabies vaccination campaign in Sri Lanka, providing estimates for the vaccination coverage achieved, analysing the local dog demographics, and identifying barriers of attendance to static vaccination clinics.

METHODS

A mass dog vaccination campaign was undertaken in Negombo, Sri Lanka. The campaign was composed of static point and door-to-door vaccination stages, with a final survey of vaccination coverage. A large volume of data on the distribution, health, and signalment of vaccinated dogs was collected through a mobile phone application. A logistic regression model was developed to investigate which socio-spatial and dog-related factors influenced attendance of owners to static vaccination points.

RESULTS

The campaign vaccinated over 7800 dogs achieving a vaccination coverage of 75.8%. A dog:human ratio of 1:17 was estimated. Most dogs were owned, and the dog population was mostly male, adult, and non-sterilized. Unawareness, unavailability and handling problems were the most common reasons given by owners to explain failure to attend a static vaccination point. The regression analysis showed that increasing distance to a static point, in addition to young age and poor health of the dog, were associated with a decrease in the likelihood of attendance to a static vaccination points.

CONCLUSION

This study demonstrates the feasibility of high number, high coverage vaccination campaigns in Sri Lanka. The information on dog ecology and barriers of attendance to static point vaccination clinics will facilitate development of future vaccination campaigns.

Rabies Antibody Response After Booster Immunization: A Systematic Review and Meta-analysis

Although fatal once symptomatic, rabies is preventable by administration of pre- and post-exposure vaccines. International guidelines suggest lifelong protection by a pre-exposure vaccination scheme followed by timely post-exposure vaccines. Rapidity and magnitude of the antibody recall response after booster inoculation are essential, as many people have been previously immunized a long time ago. The objective of this study was therefore to systematically review the evidence on the boostability of rabies immunization to date. We included 36 studies, of which 19 studies were suitable for meta-analysis. Reduced antibody levels were found after intradermal primary schedules as compared to intramuscular schedules. However, responses after booster immunization were adequate for both routes. Although studies showed that antibody levels decline over time, adequate booster responses were still retained over long time intervals indicating that post-exposure treatment is effective without extra measures after long periods of time.

A 1-week intradermal dose-sparing regimen for rabies post-exposure prophylaxis (RESIST-2): an observational cohort study

BACKGROUND

The international health authorities are backing an effort to eliminate canine-mediated rabies in humans by 2030. This effort will require improving access to adequate and timely rabies post-exposure prophylaxis as compliance is low with WHO-recommended regimens (given in four to five visits over 1 month). Access could be substantially improved by an abridged regimen to reduce doses, direct and indirect costs, and improve vaccine equity by better sharing of available vaccine. We aimed to compare rabies virus neutralising antibody titres before and after the fourth visit to determine whether that session was needed or the current regimen could be abridged.

METHODS

In this observational cohort study, we measured rabies virus neutralising antibody titres using rapid fluorescent focus inhibition tests in 116 people bitten by dogs with laboratory-confirmed rabies and 20 control individuals. Percentages of circulating plasmablasts were determined by flow cytometry. All individuals had been referred to the rabies prevention clinic at Institut Pasteur in Cambodia and received two intradermal injections of post-exposure prophylaxis on days 0, 3, 7, and 28 (Thai Red Cross regimen) with or without equine rabies immunoglobulin, as per 2010 WHO recommendations.

FINDINGS

All individuals had rabies virus neutralising antibody titres considered protective (≥0·5 IU/mL) and plasmablast activation on day 28 before the last injection. The median rabies virus neutralising antibody concentration in the group of individuals bitten by rabies virus-positive dogs was 1·08 IU/mL (IQR 0·37-3·09) on day 7, 26·86 (22·68-49·50) on day 28, and 26·74 (11·78-49·06) on day 42. No significant differences were observed in titres between days 28 and 42, after titres reached a plateau. These titres were reached notwithstanding equine rabies immunoglobulin use, age, sex, nutrition status as indicated by upper-arm circumference in children or BMI in adults, or dog infection status. Titres or plasmablast percentages did not increase between the day of the last injection and 2 weeks later. All patients were alive 1 year after post-exposure prophylaxis.

INTERPRETATION

The fourth vaccine session on day 28 provides no additional benefit. Rabies post-exposure prophylaxis can be abridged to a two-dose, three-session, 1 week regimen to improve post-exposure prophylaxis coverage and equity at no risk to patients.

FUNDING

Institut Pasteur.

Healthcare demand in response to rabies elimination campaigns in Latin America

The World Health Organization, the World Organization for Animal Health, and the Food and Agriculture Organization have resolved to eliminate human rabies deaths due to dog bites by 2030, and the Vaccine Alliance (Gavi) has added human rabies vaccines to their investments for 2021–2025. Implementing these goals cost-effectively and sustainably requires understanding the complex connections between dog rabies vaccination and human risk and response. The objective of this paper is to estimate how dog rabies vaccinations affect human rabies deaths, mediated through dog rabies cases, dog bite reporting, and post-exposure human rabies vaccination. To approach this objective, we apply multivariate regression analysis over five rabies-related outcomes: (a) dog vaccinations, (b) dog rabies cases, (c) reported human exposures, (d) human post-exposure prophylaxis (PEP) use, and (e) human rabies cases. Analysis uses aggregate annual data over 1995–2005 for seven Latin American countries that experienced dramatic declines in canine and human rabies. Among other results, we estimate the following. (i) A 10% increase in dog vaccinations decreases dog rabies cases by 2.3%. (ii) Reported exposures decline as concurrent dog rabies cases decline, but these declines are more than offset by increases in reported exposures per dog rabies case, which may result from higher rabies awareness due to anti-rabies campaigns. (iii) A 10% increase in PEP use decreases human deaths by 7%, but a 10% increase in dog vaccination induces a 2.8% decrease in PEP use. The net effect is that a 10% increase in dog vaccination reduces human deaths by 12.4% overall, although marginal effectiveness declines as dog rabies incidence declines. (iv) Increases in income and public health expenditures increase PEP demand. The findings highlight the importance of mass dog vaccination, heightened awareness, treatment access, and clinical algorithms to reduce both false negatives leading to death and false positives leading to costly unnecessary PEP prescriptions.

Several global health organizations have prioritized investment for global elimination of human death from canine rabies. Cost-effective deployment requires understanding complex connections between rabies risk and healthcare seeking behavior. During 1995–2005, there was a rapid decline in dog and human rabies cases in several Latin American countries following concerted investment in mass dog vaccinations and human post-exposure vaccination. Using data from this period, we econometrically estimate relationships between dog vaccinations, dog rabies cases, human exposure reports, human post-exposure prophylaxis (PEP) use, and human rabies deaths. We estimate quantitatively how dog vaccinations indirectly reduce human rabies deaths, mediated through dog rabies cases, dog bite reporting, and PEP use. We find that reported human exposures decline as dog rabies cases decline, but these declines are offset by increases in reported exposures per dog rabies case, which may be driven by increased rabies awareness through anti-rabies campaigns. Furthermore, while PEP demand declines as dog rabies cases decline, increases in income and public health expenditures concurrently increase demand for PEP. These findings provide better understanding of the underlying factors driving PEP demand and exposure (under)reporting to inform cost-effective policy design to reduce unnecessary PEP prescription and false negatives leading to human death.

The Cellular Immune Response to Rabies Vaccination: A Systematic Review

The effectiveness of rabies vaccines is conventionally determined by serological testing. In addition to this assessment of humoral immunity, cellular immunity could help assess effectiveness and protection through a broad range of parameters. Therefore, this study aimed to systematically review all literature on the kinetics and composition of the cellular immune response to rabies vaccination in humans. A total of 1360 studies were identified in an extensive literature search. Twenty studies were selected for inclusion. In a primary response, plasma cells are detectable from day 7 to day 14, peaking at day 10. Memory B-cells appear from day 10 up to at least day 28. After revaccination, natural killer (NK) cells are the first detectable cellular parameters. Further research is required to assess cellular parameters in relation to long-term (serological) immunity. This review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) under registration number CRD42019134416.

Combination drug treatment prolongs survival of experimentally infected mice with silver-haired bat rabies virus

Rabies is a lethal disease in humans and animals, killing approximately 60,000 people every year. Currently, there is no treatment available, except post-exposure prophylaxis (PEP) that can be administered whenever exposure to a rabid animal took place. Here we describe the beneficial effects of a combination treatment initiated at day 4 post infection, containing anti-viral drugs and immune modulators in infected mice. Combination therapy resulted in significant increase in survival time (P < 0.05) and significantly lowers viral RNA in the brain and spinal cord (P < 0.05). Furthermore, treatment influenced markers of pyroptosis and apoptosis and early inflammatory response as measured by the levels of TNF-α. Morphological lesions were absent in rabies virus infected mice with few signs of inflammation. However, these were not significant between the different groups.

Socio-spatial heterogeneity in participation in mass dog rabies vaccination campaigns, Arequipa, Peru

To control and prevent rabies in Latin America, mass dog vaccination campaigns (MDVC) are implemented mainly through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination free of charge. Dog rabies is still endemic in some Latin-American countries and high overall dog vaccination coverage and even distribution of vaccinated dogs are desired attributes of MDVC to halt rabies virus transmission. In Arequipa, Peru, we conducted a door-to-door post-campaign survey on >6,000 houses to assess the placement of vaccination points on these two attributes. We found that the odds of participating in the campaign decreased by 16% for every 100 m from the owner’s house to the nearest vaccination point (p = 0.041) after controlling for potential covariates. We found social determinants associated with participating in the MDVC: for each child under 5 in the household, the odds of participating in the MDVC decreased by 13% (p = 0.032), and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8% (p<0.001), after controlling for distance and other covariates. We also found significant spatial clustering of unvaccinated dogs over 500 m from the vaccination points, which created pockets of unvaccinated dogs that may sustain rabies virus transmission. Understanding the barriers to dog owners’ participation in community-based dog-vaccination programs will be crucial to implementing effective zoonotic disease preventive activities. Spatial and social elements of urbanization play an important role in coverage of MDVC and should be considered during their planning and evaluation.

In Peru and other dog rabies-affected countries, mass dog vaccination campaigns (MDVC) are implemented primarily through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination. To stop rabies virus transmission, a high and even dog vaccination coverage is desired. In Arequipa, Peru, following a MDVC, we conducted a door-to-door survey of >6,000 houses to assess how the placement of vaccination points affected coverage of the campaign. When comparing dog owners with similar characteristics, we found that the odds of participating in the MDVC was reduced by 16% for every 100 m distance from the nearest vaccination point. Some social conditions were also associated with participating in the MDVC: for each child under 5 in the household, odds of participating in the MDVC decreased by 13%, and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8%. Distance to the vaccination point and variation in social conditions across the city play important roles in achieving coverage of MDVC and should be considered during campaign planning and evaluation.

Rabies immune status of raccoon dogs residing in areas where rabies bait vaccine has been distributed

Since 2000, large amounts of rabies bait vaccine have been distributed in two provinces where raccoon dog-mediated rabies has occurred. A total of 146 raccoon dogs were caught in Gangwon and Gyeonggi Provinces from January 2017 to June 2018, and raccoon dog blood samples were collected. Of the 146 raccoon dogs, 13.7% (20/146) had rabies antibodies. In Gyeonggi and Gangwon provinces, the rate of rabies antibody was 8.5% (5/59) and 17.2% (15/87), respectively. Considering these results, it would be desirable to improve the distribution method or use a new bait vaccine to prevent animal rabies in South Korea.

Behavioural ecology and infectious disease: implications for conservation of biodiversity

Behaviour underpins interactions among conspecifics and between species, with consequences for the transmission of disease-causing parasites. Because many parasites lead to declines in population size and increased risk of extinction for threatened species, understanding the link between host behaviour and disease transmission is particularly important for conservation management. Here, we consider the intersection of behaviour, ecology and parasite transmission, broadly encompassing micro- and macroparasites. We focus on behaviours that have direct impacts on transmission, as well as the behaviours that result from infection. Given the important role of parasites in host survival and reproduction, the effects of behaviour on parasitism can scale up to population-level processes, thus affecting species conservation. Understanding how conservation and infectious disease control strategies actually affect transmission potential can therefore often only be understood through a behavioural lens. We highlight how behavioural perspectives of disease ecology apply to conservation by reviewing the different ways that behavioural ecology influences parasite transmission and conservation goals. This article is part of the theme issue 'Linking behaviour to dynamics of populations and communities: application of novel approaches in behavioural ecology to conservation'.

Trying to treat the untreatable: experimental approaches to clear rabies virus infection from the CNS

Rabies virus causes an invariably fatal encephalitis following the onset of clinical disease. Despite the availability of safe and effective vaccines, the clinical stages of rabies encephalitis remain untreatable, with few survivors being documented. A principal obstacle to the treatment of rabies is the neurotropic nature of the virus, with the blood-brain barrier size exclusion limit rendering the delivery of antiviral drugs and molecules to the central nervous system inherently problematic. This review focuses on efforts to try and overcome barriers to molecule delivery to treat clinical rabies and overviews current progress in the development of experimental live rabies virus vaccines that may have future applications in the treatment of clinical rabies, including the attenuation of rabies virus vectors through either the duplication or mutation of existing genes or the incorporation of non-viral elements within the genome. Rabies post-infection treatment (PIT) remains the holy grail of rabies research.

Comparison of intra- and inter-host genetic diversity in rabies virus during experimental cross-species transmission

The development of high-throughput genome sequencing enables accurate measurements of levels of sub-consensus intra-host virus genetic diversity and analysis of the role played by natural selection during cross-species transmission. We analysed the natural and experimental evolution of rabies virus (RABV), an important example of a virus that is able to make multiple host jumps. In particular, we (i) analyzed RABV evolution during experimental host switching with the goal of identifying possible genetic markers of host adaptation, (ii) compared the mutational changes observed during passage with those observed in natura, and (iii) determined whether the colonization of new hosts or tissues requires adaptive evolution in the virus. To address these aims, animal infection models (dog and fox) and primary cell culture models (embryo brain cells of dog and fox) were developed and viral variation was studied in detail through deep genome sequencing. Our analysis revealed a strong unidirectional host evolutionary effect, as dog-adapted rabies virus was able to replicate in fox and fox cells relatively easily, while dogs or neuronal dog cells were not easily susceptible to fox adapted-RABV. This suggests that dog RABV may be able to adapt to some hosts more easily than other host variants, or that when RABV switched from dogs to red foxes it lost its ability to adapt easily to other species. Although no difference in patterns of mutation variation between different host organs was observed, mutations were common following both in vitro and in vivo passage. However, only a small number of these mutations also appeared in natura, suggesting that adaptation during successful cross-species virus transmission is a complex, multifactorial evolutionary process.

Understanding the mechanisms that underpin the cross-species transmission and host adaptation of rabies virus (RABV) remains an important part of the ongoing goal to reduce and eliminate rabies. We utilized next-generation sequencing to perform a deep comparative analysis of the genomic evolution of RABV subpopulations during host adaptation in culture and in animals, with the aim of determining the molecular mechanisms involved in the host-species or tissue adaptation of rabies virus. In particular, we aimed to determine whether experimental evolution can recapitulate evolution in nature. Our results suggest that a limited number of mutations that appeared following both in vitro and in vivo passage were observed in natura. This study also suggests that dog RABV may be able to adapt to some hosts more easily than other host variants.

Transcriptional Control and mRNA Capping by the GDP Polyribonucleotidyltransferase Domain of the Rabies Virus Large Protein

Rabies virus (RABV) is a causative agent of a fatal neurological disease in humans and animals. The large (L) protein of RABV is a multifunctional RNA-dependent RNA polymerase, which is one of the most attractive targets for developing antiviral agents. A remarkable homology of the RABV L protein to a counterpart in vesicular stomatitis virus, a well-characterized rhabdovirus, suggests that it catalyzes mRNA processing reactions, such as 5'-capping, cap methylation, and 3'-polyadenylation, in addition to RNA synthesis. Recent breakthroughs in developing in vitro RNA synthesis and capping systems with a recombinant form of the RABV L protein have led to significant progress in our understanding of the molecular mechanisms of RABV RNA biogenesis. This review summarizes functions of RABV replication proteins in transcription and replication, and highlights new insights into roles of an unconventional mRNA capping enzyme, namely GDP polyribonucleotidyltransferase, domain of the RABV L protein in mRNA capping and transcription initiation.

Implementation of high coverage mass rabies vaccination in rural Uganda using predominantly static point methodology

Despite successful eradication programmes in many regions, rabies remains responsible for approximately 60,000 human deaths annually, and no country in Africa is rabies-free. Dogs are the principal reservoir of the virus in Africa and the World Health Organisation recommends that at least 70% of the dog population be vaccinated in order to break the transmission cycle. Most attempts at mass rabies vaccinations in Africa have failed to vaccinate high numbers of dogs at a high coverage. Successful studies have often used a door-to-door (DTD) approach, which is logistically challenging and expensive compared to a static point (SP) approach. Mission Rabies has successfully implemented a combined SP and DTD method in cities in India and Malawi. This campaign used a combined methodology in rural Uganda, starting with a SP campaign, followed by a DTD campaign, and then subsequent transect surveys to assess vaccination coverage. This was facilitated by the use of a smartphone application which recorded all vaccinations and survey responses along with their Global Positioning System location. A total of 4172 dogs were vaccinated in 7 days, attaining an estimated 88.4% coverage. This campaign is of particular note as 95.9% of the vaccinations were performed at SPs. The human-to-dog ratio was 4.9 with a mean dogs per house of 1.2. Most dogs were owned (93.7%). This demonstrates that high-number, high-coverage vaccination is achievable in rural Uganda and provides data that may refine future campaign approaches.

Human rabies post exposure prophylaxis at the Pasteur Institute of Dakar, Senegal: trends and risk factors

BACKGROUND

Rabies remains a major public health problem in developing countries. Most fatal rabies cases, especially in children, result from dog bites and occur in low-income countries, such as those in Sub-Saharan Africa. Rabies can be controlled through mass dog vaccination and human deaths prevented through timely and appropriate post-exposure prophylaxis (PEP). As access to appropriate PEP remains a serious challenge for bite-victims, the aim of this study was to understand the use of PEP, to evaluate the knowledge, attitudes and practices with respect to rabies and to identify risk factors related to non-compliance with PEP to define recommendations for improving PEP in Senegal.

METHODS

This study included patients with suspicion of rabies exposure who sought PEP at the Pasteur Institute of Dakar from April 2013 to March 2014. Patients with rabies clinical symptoms, those who had already started PEP and those with exposure outside Senegal or for more than 3 months were excluded. Data on risk factors and propensity to seek and complete PEP were collected using questionnaires and phone interviews. The association between acceptability and compliance with PEP and other independent variables were evaluated using multivariate regression analysis.

RESULTS

Among the 905 patients enrolled into the study, 67% were male (sex ratio M/F, 2) and 46%, children under 15 years of age. Exposures by animal bites represented 87%, whereas the remainder were due to scratches or contact; 76% were classified as WHO category III and 88% were due to dogs. Among these patients, 7% refused to start PEP and 54.5% completed the full schedule. Main factors reported by non-compliant patients were vaccine costs and affordability, and knowledge on status of biting animal.

CONCLUSION

This study shows that despite the awareness about rabies dangers and prevention, only half of the patients completed the full PEP schedule. The following recommendations, such as free of charge prophylaxis or intradermal regimens as an alternative to intramuscular regimens, should be considered to increase the adherence to PEP at the Pasteur Institute of Dakar and in Senegal.

Toll-Like Receptor 7 Enhances Rabies Virus-Induced Humoral Immunity by Facilitating the Formation of Germinal Centers

Rabies virus (RABV) causes fatal encephalitis in mammals and poses a public health threat in many parts of the world. Vaccination remains the most effective means for prevention and control of rabies. Studies focusing on the mechanism of RABV immunogenicity are necessary for improvement of rabies vaccines. Toll-like receptor 7 (TLR7), an innate receptor sensing single-stranded viral RNA, is important for the induction of innate and adaptive immunity. Our studies revealed that the absence of TLR7 led to a lower antibody production in mice immunized with RABV. It is further found that TLR7 deficiency affected the recruitment of germinal center (GC) B cells and led to lessened GCs formation. Consistently, there were less plasma cells (PCs) and antibody secreting cells (ASC) in TLR7^-/- mice than those in wild type (WT) mice, resulting in impaired production of RABV-neutralizing antibodies (VNA). TLR7 deficiency also impaired the generation of memory B cells (MBCs) and the induction of secondary immune responses. Moreover, TLR7 deficiency down-regulated the induction of some cytokines/chemokines, especially IFN-γ, resulting in a Th2-biased antibody production. Overall, our results suggest that TLR7 facilitates the induction of the humoral immunity in response to RABV.

Statistical analysis of the usefulness of follicle-sinus complexes as a novel diagnostic material for canine rabies

In the present study, follicle-sinus complexes (FSCs) were harvested from the muzzle skin of 123 dogs with suspected canine rabies, and the sensitivity and specificity of FSC analysis were compared with those of brain tissue immunohistochemistry analysis. In the FSCs, viral antigen was detected from Merkel cells. Sensitivity was 97.3%, specificity was 100%, and the coefficient κ was 0.88. These results reconfirm that FSCs are very useful for the postmortem diagnosis of canine rabies, and suggest that 5 FSCs can yield results that are almost equivalent to those derived from brain tissue analysis in rabid dogs.

Bats and Viruses: Emergence of Novel Lyssaviruses and Association of Bats with Viral Zoonoses in the EU

Bats in the EU have been associated with several zoonotic viral pathogens of significance to both human and animal health. Virus discovery continues to expand the existing understating of virus classification, and the increased interest in bats globally as reservoirs or carriers of zoonotic agents has fuelled the continued detection and characterisation of new lyssaviruses and other viral zoonoses. Although the transmission of lyssaviruses from bat species to humans or terrestrial species appears rare, interest in these viruses remains, through their ability to cause the invariably fatal encephalitis—rabies. The association of bats with other viral zoonoses is also of great interest. Much of the EU is free of terrestrial rabies, but several bat species harbor lyssaviruses that remain a risk to human and animal health. Whilst the rabies virus is the main cause of rabies globally, novel related viruses continue to be discovered, predominantly in bat populations, that are of interest purely through their classification within the lyssavirus genus alongside the rabies virus. Although the rabies virus is principally transmitted from the bite of infected dogs, these related lyssaviruses are primarily transmitted to humans and terrestrial carnivores by bats. Even though reports of zoonotic viruses from bats within the EU are rare, to protect human and animal health, it is important characterise novel bat viruses for several reasons, namely: (i) to investigate the mechanisms for the maintenance, potential routes of transmission, and resulting clinical signs, if any, in their natural hosts; (ii) to investigate the ability of existing vaccines, where available, to protect against these viruses; (iii) to evaluate the potential for spill over and onward transmission of viral pathogens in novel terrestrial hosts. This review is an update on the current situation regarding zoonotic virus discovery within bats in the EU, and provides details of potential future mechanisms to control the threat from these deadly pathogens.

Transmissible vaccines whose dissemination rates vary through time, with applications to wildlife

Transmission is a potential property of live viral vaccines that remains largely unexploited but may lie within the realm of many engineering designs. While likely unacceptable for vaccines of humans, transmission may be highly desirable for vaccines of wildlife, both to protect natural populations and also to limit zoonotic transmissions into humans. Defying intuition, transmission alone does not guarantee that a vaccine will perform well: the benefit of transmission over no transmission depends on and increases with the basic reproductive number of the vaccine, R₀. The R₀ of an infectious agent in a homogeneous population is typically considered to be a fixed number, but some evidence suggests that dissemination of transmissible vaccines may change through time. One obvious possibility is that transmission will be greater from hosts directly vaccinated than from hosts who acquire the vaccine passively, but other types of change might also accrue. Whenever transmission changes over time, the R₀ estimated from directly vaccinated hosts will not reflect the vaccine's long term impact. As there is no theory on the consequences of changing transmission rates for a vaccine, we derive conditions for a transmissible vaccine with varying transmission rates to protect a population from pathogen invasion. Being the first in the transmission chain, the R₀ from directly vaccinated hosts has a larger effect than those from later steps in the chain. This mathematical property reveals that a transmissible vaccine with low long term transmission may nonetheless realize a big impact if early transmission is high. Furthermore, there may be ways to artificially elevate early transmission, thereby achieving high herd immunity from transmission while ensuring that the vaccine will ultimately die out.

Mechanisms for lyssavirus persistence in non-synanthropic bats in Europe: insights from a modeling study

Bats are natural reservoirs of the largest proportion of viral zoonoses among mammals, thus understanding the conditions for pathogen persistence in bats is essential to reduce human risk. Focusing on the European Bat Lyssavirus subtype 1 (EBLV-1), causing rabies disease, we develop a data-driven spatially explicit metapopulation model to investigate EBLV-1 persistence in Myotis myotis and Miniopterus schreibersii bat species in Catalonia. We find that persistence relies on host spatial structure through the migratory nature of M. schreibersii, on cross-species mixing with M. myotis, and on survival of infected animals followed by temporary immunity. The virus would not persist in the single colony of M. myotis. Our study provides for the first time epidemiological estimates for EBLV-1 progression in M. schreibersii. Our approach can be readily adapted to other zoonoses of public health concern where long-range migration and habitat sharing may play an important role.

Priorities in applied research to ensure programmatic success in the global elimination of canine rabies

The elimination of human rabies mediated by dogs is attainable in concept, based upon current sensitive and specific diagnostic methods, existing safe and effective human and veterinary vaccines and a sound virological, pathological and epidemiological understanding of the disease. Globally, all developed countries achieved this goal. Regionally, major progress occurred throughout the Americas. However, less advancement is evident in Africa and Asia. Our objective was to concentrate upon those salient improvements to extant tools and methods over the next five years which could assist and simplify the task for both those developing countries that have already begun the process, as well as other localities in the earlier stages of consideration. We considered several categories of applied research which could be accomplished in the short term, based upon the available scientific evidence and recent recommendations from subject matter experts and key opinion leaders, focused upon perceived major limitations to prior program success. Areas of concentration included: laboratory-based surveillance, pathogen detection and characterization; human rabies prophylaxis; veterinary biologics; implementation of canine vaccination; and oral vaccination of free-ranging community dogs. Further real-time application in these core areas with proven techniques and technology would simplify attaining not only the global goal focused subtly upon human mortality, but the actual elimination of canine rabies as well.

Memantine can relieve the neuronal impairment caused by neurotropic virus infection

Neurotropic viruses, such as the rabies virus (RABV) and Japanese encephalitis virus (JEV), induce neuronal dysfunction and complication, causing neuronal damage. Currently, there are still no effective clinical treatments for neuronal injury caused by neurotropic viruses. Memantine, a drug capable of passing through the blood-brain barrier, noncompetitively and reversibly binds to n-methyl- d-aspartic acid (NMDA) receptors. Memantine is used to treat Alzheimer's disease by blocking the activation of extra axonal ion channels, thus preventing neuronal degeneration by inhibiting the abnormal cytosolic Ca ²⁺ increase. To explore whether memantine can alleviate neurological disturbances caused by RABV and JEV, the following experiments were carried out: (1) for primary neurons cultured in vitro infected with RABV, the addition of memantine showed neuroprotection. (2) In the RABV challenge experiments, memantine had limited therapeutic effect, mildly extending the survival time of mice. In contrast, memantine significantly prolonged the survival time of mice infected with JEV, by reducing the intravascular cuff and inflammatory cell infiltration in mice. Furthermore, memantine decreases the amount of JEV virus in mice brain.

A high throughput neutralization test based on GFP expression by recombinant rabies virus

The effectiveness of rabies vaccination in both humans and animals is determined by the presence of virus neutralizing antibodies (VNAs). The Rapid Fluorescent Focus Inhibition Test (RFFIT) is the method traditionally used for detection and quantification of VNAs. It is a functional in vitro test for assessing the ability of antibodies in serum to bind and prevent infection of cultured cells with rabies virus (RABV). The RFFIT is a labor intensive, low throughput and semi-quantitative assay performed by trained laboratorians. It requires staining of RABV-infected cells by rabies specific fluorescent antibodies and manual quantification of fluorescent fields for titer determination. Although the quantification of fluorescent fields observed in each sample is recorded, the corresponding images are not stored or captured to be used for future analysis. To circumvent several of these disadvantages, we have developed an alternative, automated high throughput neutralization test (HTNT) for determination of rabies VNAs based on green fluorescent protein (GFP) expression by a recombinant RABV and compared with the RFFIT. The HTNT assay utilizes the recombinant RABV ERA variant expressing GFP with a nuclear localization signal (NLS) for efficient quantification. The HTNT is a quantitative method where the number of RABV-infected cells are determined and the images are stored for future analysis. Both RFFIT and HTNT results correlated 100% for a panel of human and animal positive and negative rabies serum samples. Although, the VNA titer values are generally agreeable, HTNT titers tend to be lower than that of RFFIT, probably due to the differences in quantification methods. Our data demonstrates the potential for HTNT assays in determination of rabies VNA titers.

The potency of rabies vaccine is demonstrated by the presence of virus neutralizing antibodies (VNAs) in serum. It is critical to evaluate immunologic status of individuals who work directly with rabies virus (RABV) (laboratorians) or at high risk of infection due to interaction with animals (veterinarians and animal control workers). In addition, rabies vaccination records and demonstration of VNAs in animals are mandatory before initiating pet travel to rabies-free counties or regions. Rabies VNAs are currently determined by the rapid fluorescent focus inhibition test (RFFIT) and the fluorescent antibody virus neutralization (FAVN) test, which measure the ability of antibodies to bind and prevent infection of RABV in vitro. Both assays require staining of infected cells using anti-rabies antibodies and manual observation of infected cells by a fluorescent microscope to determine VNA titers. In this study, we have developed a GFP reporter-based high throughput neutralization test (HTNT) for automated quantification of infected cells. This method has the advantages of allowing investigators to analyze and store the results, and can accommodate large sample sizes. Overall, the results from HTNT exhibited 100% correlation with that of RFFIT, albeit with differences in rabies VNA titer values due to quantification methods.

Evaluation of six TaqMan RT-rtPCR kits on two thermocyclers for the reliable detection of rabies virus RNA

Rabies is diagnosed postmortem in animals, based on tests prescribed by the World Organization for Animal Health (OIE), such as the fluorescent antibody test, the direct rapid immunohistochemistry test, or pan-lyssavirus PCR assays. Several reverse-transcription real-time PCR (RT-rtPCR) methods have been developed and validated for rapid and accurate detection of lyssaviruses. We evaluated the performance of 6 TaqMan RT-rtPCR kits using different commercial master mixes and 2 real-time thermocyclers. Changing the master mix overall did not influence the TaqMan RT-rtPCR performance, regardless of the thermocycler used. The limits of detection at the 95% confidence level were 18.1-25.8 copies/µL for the Rotor-Gene Q MDx thermocycler and 16.7-21.5 for the Mx3005P thermocycler. Excellent repeatability was demonstrated for rabies virus (RABV) RNA samples of 100, 50, and 25 copies/µL regardless of the thermocycler used. RABV field samples ( n = 35) isolated worldwide gave positive results using the most efficient of the 6 kits tested, with a copy number of 6.03 × 10² to 6.78 × 10⁷ RNA copies per reaction. The TaqMan RT-rtPCR assay provides sensitive and rapid amplification of RABV RNA.

Follicle sinus complexes (FSCs) in muzzle skin as postmortem diagnostic material of rabid dogs

Recently, we reported that follicle-sinus complexes (FSCs) in the muzzle skin are useful for postmortem diagnosis of rabid dogs. Here, we compared the sensitivity and specificity of detecting the viral antigen in the brain and FSCs of 226 suspected rabid dogs, and assessed whether the FSC harbored the virus genome and particles. The viral antigen was detected in 211 of 226 samples with 100% sensitivity and specificity. Viral RNA and particles were observed in the cytoplasm of Merkel cells (MCs). These results suggest that MCs are targets of virus infection and FSCs are useful material for diagnosing rabies.

Modeling the Transmission Dynamics of Rabies for Dog, Chinese Ferret Badger and Human Interactions in Zhejiang Province, China

Human rabies is one of the major public health problems in China with an average of 1977 cases per year. It is estimated that 95% of these human rabies cases are due to dog bites. In recent years, the number of wildlife-associated human rabies cases has increased, particularly in the southeast and northeast regions of mainland China. Chinese ferret badgers (CFBs) are one of the most popular wildlife animals which are distributed mostly in the southeast region of China. Human cases caused by rabid CFB were first recorded in Huzhou, Zhejiang Province, in 1994. From 1996 to 2004, more than 30 human cases were caused by CFB bites in Zhejiang Province. In this paper, based on the reported data of the human rabies caused by both dogs and CFB in Zhejiang Province, we propose a multi-host zoonotic model for the dog-CFB-human transmission of rabies. We first evaluate the basic reproduction number [Formula: see text] discuss the stability of the disease-free equilibrium, and study persistence of the disease. Then we use our model to fit the reported data in Zhejiang Province from 2004 to 2017 and forecast the trend of human or livestock rabies. Finally by carrying out sensitivity analysis of the basic reproduction number in terms of parameters, we find that the transmission between dogs and CFB, the quantity of dogs, and the vaccination rate of dogs play important roles in the transmission of rabies. Our study suggests that rabies control and prevention strategies should include enhancing public education and awareness about rabies, increasing dog vaccination rate, reducing the dog and CFB interactions, and avoiding CFB bites or contact.

Transmission dynamics of re-emerging rabies in domestic dogs of rural China

Despite ongoing efforts to control transmission, rabies prevention remains a challenge in many developing countries, especially in rural areas of China where re-emerging rabies is under-reported due to a lack of sustained animal surveillance. By taking advantage of detailed genomic and epidemiological data for the re-emerging rabies outbreak in Yunnan Province, China, collected between 1999 and 2015, we reconstruct the demographic and dispersal history of domestic dog rabies virus (RABV) as well as the dynamics of dog-to-dog and dog-to-human transmission. Phylogeographic analyses reveal a lower diffusion coefficient than previously estimated for dog RABV dissemination in northern Africa. Furthermore, epidemiological analyses reveal transmission rates between dogs, as well as between dogs and humans, lower than estimates for Africa. Finally, we show that reconstructed epidemic history of RABV among dogs and the dynamics of rabid dogs are consistent with the recorded human rabies cases. This work illustrates the benefits of combining phylogeographic and epidemic modelling approaches for uncovering the spatiotemporal dynamics of zoonotic diseases, with both approaches providing estimates of key epidemiological parameters.

Canine rabies control and human exposure 1951-2015, Guangzhou, China

Objective

To describe changes in rabies surveillance and management in Guangzhou, China between 1951 and 2015, and to analyse human rabies cases over that period.

Methods

Rabies control policies and strategies implemented by the Guangzhou government were reviewed for three periods: 1951 to 1978, 1979 to 2000 and 2001 to 2015. Data on human rabies deaths and exposure were obtained from Guangzhou and national health and disease records. The demographic characteristics of human cases are reported using descriptive statistics.

Findings

Between 1951 and 2015, the number of organizations cooperating on rabies control increased: there were two between 1951 and 1978, six between 1979 and 2000, and nine between 2001 and 2015. The number of human rabies cases reported in these periods was 331, 422 and 60, respectively. Organizations involved included city and district centres for disease control and prevention, rabies outpatient clinics, medical institutions and police. Overall, 88% (713/813) of cases occurred in rural districts, though, between 1951 and 2015, the distribution shifted from being predominantly rural to being both urban and rural. The number of people exposed to rabies increased annually. The biggest increases were among those injured by a pet dog or other animal: 3.26 and 4.75 times, respectively, between 2005 and 2015.

Conclusion

Increased cooperation on rabies control between civil organizations in Guangzhou over decades was associated with a marked decrease in the number of human rabies cases. The Guangzhou experience could thereby provide guidance for other cities experiencing similar rabies epidemics.

A metapopulation model of dog rabies transmission in N'Djamena, Chad

Rabies transmission was interrupted for several months in N'Djamena, the capital city of Chad, after two mass vaccination campaigns of dogs. However, there was a resurgence in cases, which was not predicted by previous models of rabies transmission. We developed a deterministic metapopulation model with importation of latent dogs, calibrated to four years of weekly incidence data from passive surveillance, to investigate possible causes for the early resurgence. Our results indicate that importation of latently infective dogs better explains the data than heterogeneity or underreporting. Stochastic implementations of the model suggest that the two vaccination campaigns averted approximately 67 cases of dog rabies (out of an estimated 74 cases without vaccination) and 124 human exposures (out of an estimated 148 human exposures without vaccination) over two years. Dog rabies vaccination is therefore an effective way of preventing rabies in the dog population and to subsequently reduce human exposure. However, vaccination campaigns have to be repeated to maintain the effect or reintroduction through importation has to be prevented.

Human rabies control in Lebanon: a call for action

The status of rabies as a neglected disease has made its eradication rather challenging in different parts of the world despite the availability of a successful vaccine. Lebanon, in particular, is a country endemic to the disease with several cases of rabies deaths reported over the past 30 years. The risk of rabies, however, has taken a new turn over the past few years in Lebanon with two emerging situations that have made the control of the disease rather challenging: the neighbouring Syrian war and the local garbage crisis. Both of these milestone events might have contributed to an increase in the number of disease vectors as well as individuals at risk, thus nourishing the cycle of disease transmission. In this observational study, the effect of these two events are investigated, with an update on the status of this preventable, yet often neglected, disease in the country. Both events were found to be concomitant with a notable increase in the number of dog bites and thus possible rabies exposure. Current regulations are explored through interviews with veterinarians, and custom recommendations, ranging from policies to control dog populations to awareness campaigns in high-risk individuals, are then proposed to help control the disease.

Application of a novel nanoemulsion adjuvant for rabies vaccine which stabilizes a Krebs cycle intermediate (SDH) in an animal model

Rabies is the most lethal zoonotic, vaccine-preventable viral disease in the world. Its treatment is complicated by insufficient vaccine supply and the requirement for four to five repeated injections, as commercially available inactivated rabies lack adjuvant and have low immunogenicity. In this study, we focused on the role of a Krebs cycle intermediate, succinate dehydrogenase (SDH), in the innate immune response to cytokine production. We formulated a novel nanoemulsion adjuvant, Golden03, which stabilizes mouse SDH activity and contains more coenzyme Q10 and succinic acid than the classic MF59 adjuvant. Mice were immunized on days 1, 3, and 7, with seroconversion rate results suggesting that Golden03 significantly enhanced vaccine-stimulated antibody production against the rabies virus. Neutralizing antibody concentration testing by RFFIT indicated that treatment with Golden03 could result in antibody levels of up to 0.74 IU/mL 5 days post infection (DPI). ELISPOT for IFN-γ in mouse spleen cells showed that Golden03 enhanced immune responses at 14 DPI, inducing a rapid and powerful cellular response compared to the control group. Furthermore, the Vaccine-Golden03 group displayed no obvious weight loss or death after intracranial injection with CVS-11. An additional advantage is that Golden03 allowed for a three-quarter reduction in dose, while maintaining its efficacy and rapid stimulation effect. We suggest that Golden03 could be developed as a potential adjuvant for use in human rabies vaccine.

RECENT CHANGES IN INFECTIOUS DISEASES IN EUROPEAN WILDLIFE

Many infectious diseases originating from, or carried by, wildlife affect wildlife conservation and biodiversity, livestock health, or human health. We provide an update on changes in the epidemiology of 25 selected infectious, wildlife-related diseases in Europe (from 2010-16) that had an impact, or may have a future impact, on the health of wildlife, livestock, and humans. These pathogens were selected based on their: 1) identification in recent Europe-wide projects as important surveillance targets, 2) inclusion in European Union legislation as pathogens requiring obligatory surveillance, 3) presence in recent literature on wildlife-related diseases in Europe since 2010, 4) inclusion in key pathogen lists released by the Office International des Epizooties, 5) identification in conference presentations and informal discussions on a group email list by a European network of wildlife disease scientists from the European Wildlife Disease Association, or 6) identification as pathogens with changes in their epidemiology during 2010-16. The wildlife pathogens or diseases included in this review are: avian influenza virus, seal influenza virus, lagoviruses, rabies virus, bat lyssaviruses, filoviruses, canine distemper virus, morbilliviruses in aquatic mammals, bluetongue virus, West Nile virus, hantaviruses, Schmallenberg virus, Crimean-Congo hemorrhagic fever virus, African swine fever virus, amphibian ranavirus, hepatitis E virus, bovine tuberculosis ( Mycobacterium bovis), tularemia ( Francisella tularensis), brucellosis ( Brucella spp.), salmonellosis ( Salmonella spp.), Coxiella burnetii, chytridiomycosis, Echinococcus multilocularis, Leishmania infantum, and chronic wasting disease. Further work is needed to identify all of the key drivers of disease change and emergence, as they appear to be influencing the incidence and spread of these pathogens in Europe. We present a summary of these recent changes during 2010-16 to discuss possible commonalities and drivers of disease change and to identify directions for future work on wildlife-related diseases in Europe. Many of the pathogens are entering Europe from other continents while others are expanding their ranges inside and beyond Europe. Surveillance for these wildlife-related diseases at a continental scale is therefore important for planet-wide assessment, awareness of, and preparedness for the risks they may pose to wildlife, domestic animal, and human health.

[Rabies and Bornavirus encephalitis : Fatal emerging viral encephalitis-a potential problem for organ recipients]

A severe, often fatal encephalitis needs to be extensively and carefully clarified, especially when it occurs in a patient weeks or months after an organ transplantation. If the donor was viremic at the time of the organ removal or living viruses were present in the organ tissue, many viruses can be transferred to the organ recipient. This has been repeatedly reported in recent years and decades. In this overview rabies is discussed as a particularly important form of viral encephalitis, which is transferred via organs and always has a fatal outcome, because patients carry a high risk of infection for all caregivers. Bornavirus has been known in veterinary medicine for many decades and in human medicine has been discussed as possibly being associated with psychiatric diseases. Very recently Bornavirus has been identified as the causative pathogen of fatal encephalitis in organ recipients. The aim of this article is to raise awareness for rabies and Bornavirus disease in intensive care medicine and neurology for organ donors and those taking care of organ recipients. Prevention by knowledge can be lifesaving.

Surveillance of Rabies Postexposure Prophylaxis in Greece: 4 Years Experience

Rabies reemerged in Greek fauna during October 2012, 25 years after the last report in animals and 42 after the last human case. This study examined the administration of rabies postexposure prophylaxis (PEP) in humans over the period 2012-2016. A total of 1,454 individuals (62.6% males) received PEP. The vast majority (92.3%) of regimens was initiated in high risk for animal rabies areas (11.1 PEP per 100,000 residents per year). Among the exposed, 77.0% presented at a healthcare setting during the first 24 h after the incident; more severe injuries were associated with faster presentation (p < 0.05). A vaccine series was administered in 54.5% of exposed persons whereas 43.7% received both vaccine and immunoglobulin and 1.7% immunoglobulin only. Exposure to stray dogs represented 68.4% of all incidents. In exposures occurring in nonhigh risk for rabies areas, bat was the second most frequently involved animal (13.4% of incidents). All dogs and cats evaluated by a veterinarian and laboratory-confirmed rabid were initially deemed suspect for rabies during clinical examination or according to history. No human rabies cases were recorded during the period of the study. Surveillance of PEP represents a valuable tool for aiding assessment of present and future demands in prophylaxis biologicals, outlining the epidemiological profile of exposures and planning effective policies for the management of exposure incidents.

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.

Improving systematic rabies surveillance in Cameroon: A pilot initiative and results for 2014-2016

Canine rabies is endemic in Cameroon, but human rabies exposures and cases are likely underreported because of inadequate surveillance. In 2014, the surveillance network in the West region of Cameroon was reinforced by introducing a new anti-rabies center, a framework for data collection and evaluation, provisions for sample collecting and laboratory confirmation, and training for health professionals. The objective of this observational cohort study was to describe the incidence and characteristics of reported exposures and human and animal rabies cases following this reinforcement of the existing rabies surveillance system. The surveillance network consisted of local, regional, and national health and veterinary authorities in 11 of the 20 West region districts, and was completely integrated within the existing national rabies surveillance network. Animal exposures and suspected rabies exposures, the suspected rabid animals involved, and laboratory confirmation of human and animal rabies cases were recorded in a centralized information database. Between January 2014 and June 2016, the network recorded 1340 animal exposure cases for an overall incidence rate of 38.2 animal exposures per 100,000 people, four confirmed rabies-positive animals, and one confirmed human rabies case out of four clinically suspected cases. In contrast, 62 animal exposures and an overall incidence rate of 6.1 exposures per 100,000 people were reported for the West region districts not participating in the reinforced surveillance. Of the 925 animal exposure victims for whom a detailed case report form was completed, 703 were considered to be at risk of rabies and only 428 (61%) of these received any post-exposure prophylaxis in the form of rabies vaccine. Obstacles encountered within the network included low rates of animal sample submission and animal follow-up by veterinarians. Reinforced rabies surveillance in the West region of Cameroon has provided the most accurate estimate of the region's disease and exposure burdens to date, and indicates that animal exposures are substantially underreported. The reinforced network also signaled that greater access to post-exposure prophylaxis is needed. Integration of regions not covered by the surveillance network and efforts to improve engagement of veterinary services will be needed to reveal the true burden of rabies in Cameroon.

Long term trends and spatial distribution of animal bite injuries and deaths due to human rabies infection in Uganda, 2001-2015

BACKGROUND

In the absence of accurate data on trends and the burden of human rabies infection in developing countries, animal bite injuries provide useful information to bridge that gap. Rabies is one of the most deadly infectious diseases, with a case fatality rate approaching 100%. Despite availability of effective prevention and control strategies, rabies still kills 50,000 to 60,000 people worldwide annually, the majority of whom are in the developing world. We describe trends and geographical distribution of animal bite injuries (a proxy of potential exposure to rabies) and deaths due to suspected human rabies in Uganda from 2001 to 2015.

METHODS

We used 2001-2015 surveillance data on suspected animal bite injuries, collected from health facilities in Uganda. To describe annual trends, line graphs were used and linear regression tested significance of observed trends at P<0.05. We used maps to describe geographical distribution of animal bites by district.

RESULTS

A total of 208,720 cases of animal bite injuries were reported. Of these, 27% were in Central, 22% in Eastern, 27% in Northern and 23% in Western regions. Out of 48,720 animal bites between 2013 and 2015, 59% were suffered by males and 81% were persons aged above 5 years. Between 2001 and 2015, the overall incidence (per 100,000 population) of animal bites was 58 in Uganda, 76 in Northern, 58 in Central, 53 in Western and 50 in Eastern region. From 2001 to 2015, the annual incidence (per 100,000 population) increased from 21 to 47 (P = 0.02) in Central, 27 to 34 (P = 0.04) in Eastern, 23 to 70 (P = 0.01) in Northern and 16 to 46 (P = 0.001) in Western region. A total of 486 suspected human rabies deaths were reported, of which 29% were reported from Eastern, 28% from Central, 27% from Northern and 17% from Western region.

CONCLUSION

Animal bite injuries, a potential exposure to rabies infection, and mortality attributed to rabies infection are public health challenges affecting all regions of Uganda. Eliminating rabies requires strengthening of rabies prevention and control strategies at all levels of the health sector. These strategies should utilize the "One Health" approach with strategic focus on strengthening rabies surveillance, controlling rabies in dogs and ensuring availability of post exposure prophylaxis at lower health facilities.

Analysis of expression profiles of long noncoding RNAs and mRNAs in brains of mice infected by rabies virus by RNA sequencing

Rabies, caused by rabies virus (RABV), is still the deadliest infectious disease. Mechanism of host immune response upon RABV infection is not yet fully understood. Accumulating evidences suggest that long noncoding RNAs (lncRNAs) plays key roles in host antiviral responses. However, expression profile and function of lncRNAs in RABV infection remain unclear. In the present study, expression profile of lncRNAs and mRNAs profiles were investigated in RABV-infected brain tissues of mice by RNA sequencing. A total of 140 lncRNAs and 3,807 mRNAs were differentially expressed in RABV-infected animals. The functional annotation and enrichment analysis using Gene Oncology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) revealed that differentially expressed transcripts were predominantly involved in signaling pathways related to host immune response. The expression profiles of the selected lncRNAs in brains of mice during RABV infections were verified by quantitative real time polymerase chain reaction (qRT-PCR). To our knowledge, this is the first report to profile the lncRNA expression in RABV infected mice. Our findings provide insights into understanding the role of lncRNAs in host immune response against RABV infection.