Epidemiological study of human rabies cases in Bangladesh through verbal autopsy

Rabies control in Bangladesh and prediction of human rabies cases by 2030: a One Health approach

Background

Bangladesh is making progress toward achieving zero dog-mediated rabies deaths by 2030, a global goal set in 2015.

Methods

Drawing from multiple datasets, including patient immunisation record books and mass dog vaccination (MDV) databases, we conducted a comprehensive analysis between 2011 and 2023 to understand the effectiveness of rabies control programmes and predict human rabies cases in Bangladesh by 2030 using time-series forecasting models. We also compared rabies virus sequences from GenBank in Bangladesh and other South Asian countries.

Findings

The estimated dog population in Bangladesh was determined to be 1,668,140, with an average dog population density of 12.83 dogs/km2 (95% CI 11.14-14.53) and a human-to-dog ratio of 86.70 (95% CI 76.60-96.80). The MDV campaign has led to the vaccination of an average of 21,295 dogs (95% CI 18,654-23,935) per district annually out of an estimated 26,065 dogs (95% CI 22,898-29,230). A declining trend in predicted and observed human rabies cases has been identified, suggesting that Bangladesh is poised to make substantial progress towards achieving the 'Zero by 30' goal, provided the current trajectory continues. The phylogenetic analysis shows that rabies viruses in Bangladesh belong to the Arctic-like-1 group, which differs from those in Bhutan despite sharing a common ancestor.

Interpretation

Bangladesh's One Health approach demonstrated that an increase in MDV and anti-rabies vaccine (ARV) resulted in a decline in the relative risk of human rabies cases, indicating that eliminating dog-mediated human rabies could be achievable.

Funding

The study was supported by the Communicable Disease Control (CDC) Division of the Directorate General of Health Services (DGHS) of the People's Republic of Bangladesh.

Puppies as the primary causal animal for human rabies cases: three-year prospective study of human rabies in the Philippines

Introduction

While rabies remains a global concern, detailed studies on human rabies, particularly regarding causal animals and the reasons for not receiving postexposure prophylaxis (PEP), are lacking.

Methods

We conducted a 3-year prospective study (October 2019-September 2022) at the Philippines' largest rabies referral center. We interviewed patients with suspected rabies and their families. We used LN34 qRT-PCR and rapid fluorescent focus inhibition test on saliva samples. We also compared our findings with two retrospective studies at the same hospital.

Results

We enrolled 151 patients, including 131 with potential rabies exposure. Similar to retrospective studies, the participants were predominantly males (75.5%), adults (76.8%), low-income individuals (91.4%), and rural dwellers (62.3%). The causal animals were mainly dogs (97.0%), with similar incubation periods, clinical symptoms, and a high proportion not receiving vaccines or immunoglobulins (93.2%). Most causal animals were owned by either the patients' households or their neighbors (60.2%), with a significant proportion being puppies (58.8%). Most patients had knowledge of rabies; however, reasons for not seeking PEP included misconceptions about minor bites not causing rabies (51.3%), beliefs in traditional healers (33.9%), and economic constraints (22.6%). Despite completing the WHO regimen, two PEP failures were observed. LN34 qRT-PCR detected 98 positive cases (sensitivity, 64.9%; 95% CI 56.7-72.5). These strains belong to the Southeast Asia 4 subclade.

Discussion

In conclusion, this study highlights the role of puppies as primary causal animals and the presence of misconceptions that preclude patients from acquiring PEP.

Risk mapping and risk factors analysis of rabies in livestock in Bangladesh using national-level passive surveillance data

Rabies is a major zoonotic disease around the world, causing significant mortality to both humans and animals, especially in low- and middle-income countries. In Bangladesh, rabies is transmitted mostly by the bite of infected dogs and jackals to humans and domestic livestock, causing severe economic losses and public health hazards. Our study analyzed national passive surveillance data of veterinary hospital-reported rabies cases in cattle, buffalo, sheep, and goats from 2015 to 2017 in all 64 districts of Bangladesh. We used a zero-inflated negative binomial regression model to identify the main environmental and socio-economic risk factors associated with rabies occurrence in livestock, and we used model results to generate risk maps. Our study revealed that monsoon precipitation (RR=1.28, p-value=0.043) was positively associated with rabies cases in livestock, and the percentage of adults who have completed university education was also a significant predictor (RR=0.58, p-value<0.001) likely suggesting that districts with higher education levels tended to have a lower reporting of rabies cases in livestock. The standardized incidence ratio maps and predicted relative risk maps revealed a high risk of rabies cases in southeast areas in Bangladesh. We recommend implementing risk-based vaccination strategies in dogs and jackals in those high-risk areas before monsoon to reduce the burden of rabies cases in domestic ruminants and humans in Bangladesh.

Rabies in the SAARC region: An epidemiological study of disease burden and challenges

Our original study explored trends in rabies-related cases in the South Asian Association for Regional Cooperation region from 2017 to 2021. We analyzed population-level data from Global Health Observatory, World Animal Health Information Database and media reports using Microsoft Excel v.2016. Rabies prevalence varied with India experiencing the highest increase, while Bhutan reported a significant decrease. In contrast, Nepal and Pakistan observed fluctuations, emphasizing the need for ongoing intervention.

Rabies in a postpandemic world: resilient reservoirs, redoubtable riposte, recurrent roadblocks, and resolute recidivism

Rabies is an ancient disease. Two centuries since Pasteur, fundamental progress occurred in virology, vaccinology, and diagnostics-and an understanding of pathobiology and epizootiology of rabies in testament to One Health-before common terminological coinage. Prevention, control, selective elimination, and even the unthinkable-occasional treatment-of this zoonosis dawned by the twenty-first century. However, in contrast to smallpox and rinderpest, eradication is a wishful misnomer applied to rabies, particularly post-COVID-19 pandemic. Reasons are minion. Polyhostality encompasses bats and mesocarnivores, but other mammals represent a diverse spectrum of potential hosts. While rabies virus is the classical member of the genus, other species of lyssaviruses also cause the disease. Some reservoirs remain cryptic. Although global, this viral encephalitis is untreatable and often ignored. As with other neglected diseases, laboratory-based surveillance falls short of the notifiable ideal, especially in lower- and middle-income countries. Calculation of actual burden defaults to a flux within broad health economic models. Competing priorities, lack of defined, long-term international donors, and shrinking local champions challenge human prophylaxis and mass dog vaccination toward targets of 2030 for even canine rabies impacts. For prevention, all licensed vaccines are delivered to the individual, whether parenteral or oral-essentially 'one and done'. Exploiting mammalian social behaviors, future 'spreadable vaccines' might increase the proportion of immunized hosts per unit effort. However, the release of replication-competent, genetically modified organisms selectively engineered to spread intentionally throughout a population raises significant biological, ethical, and regulatory issues in need of broader, transdisciplinary discourse. How this rather curious idea will evolve toward actual unconventional prevention, control, or elimination in the near term remains debatable. In the interim, more precise terminology and realistic expectations serve as the norm for diverse, collective constituents to maintain progress in the field.

Clinical, epidemiological, and spatial features of human rabies cases in Metro Manila, the Philippines from 2006 to 2015

Rabies remains a public health problem in the Philippines despite the widespread provision of rabies vaccines and rabies immunoglobulin (RIG) as post-exposure prophylaxis (PEP). Detailed descriptions of recent human rabies cases in the Philippines are scarce. This study aimed to describe the clinical, epidemiological, and spatial features of human rabies cases between January 1, 2006, and December 31, 2015. We conducted a retrospective hospital-based case record review of all patients admitted to one referral hospital in Manila who received a clinical diagnosis of rabies. During the 10-year study period there were 575 patients (average 57.5 cases per year, range 57 to 119) with a final diagnosis of rabies. Most patients were male (n = 404, 70.3%) and aged ≥ 20 years (n = 433, 75.3%). Patients mostly came from the National Capital Region (n = 160, 28.0%) and the adjacent Regions III (n = 197, 34.4%) and IV-A (n = 168, 29.4%). Case mapping and heatmaps showed that human rabies cases were continuously observed in similar areas throughout the study period. Most patients had hydrophobia (n = 444, 95.5%) and/or aerophobia (n = 432, 93.3%). The leading causative animals were dogs (n = 421, 96.3%) and cats (n = 16, 3.7%). Among 437 patients with animal exposure history, only 42 (9.6%) had been administered at least one rabies vaccine. Two patients (0.5%), young children bitten on their face, had received and a full course of rabies vaccine. Human rabies patients were continuously admitted to the hospital, with no notable decline over the study period. The geographical area in which human rabies cases commonly occurred also did not change. Few patients received PEP and there were two suspected cases of PEP failure. The retrospective design of this study was a limitation; thus, prospective studies are required.

Rabies remains a public health problem in the Philippines despite improvements in the availability of rabies vaccines and rabies immunoglobulin (RIG) as post-exposure prophylaxis (PEP). The incidence of rabies is highest in Metro Manila and surrounding areas. We reviewed the records of all human rabies patients admitted to the national infectious disease hospital in Manila between 2006 and 2015. This hospital treats most cases in this area. During the 10-year study period, human rabies cases were continuously admitted to the hospital, with no notable decline in numbers by year. Most patients were adult men bitten by domestic dogs. The geographical areas in which cases commonly occurred during the 10-year period also did not change over time. Only 9.6% of patients had received at least one dose of a rabies vaccine as PEP. Although the risk of PEP failure is reported to be almost zero, we identified two suspected cases of PEP failure. The retrospective design of this study was a limitation, and the exact details of PEP were not reliably available. As human rabies death is a significant public health concern, the circumstances of each case should be prospectively investigated. Further research is required to understand how to reduce the number of rabies cases.

Evidence mapping of current status, impact, prevention and control measures from rabies research in Bangladesh (2010-2021): a scoping review protocol

INTRODUCTION

Rabies is one of the priority zoonotic diseases in Bangladesh. Though the rabies cases have been reduced over the years due to the mass dog vaccination programme since 2011 throughout the country, it is still a major health problem in Bangladesh with an annual estimated 200 000 animal bite cases and over 2000 human deaths. This article presented a scoping review protocol for published literature on rabies in Bangladesh and believes to create impact in Bangladesh by identifying the research gap and guiding the evidence-informed policy adaptation from its findings in the future which will strongly underscore the elimination of Rabies and reduce preventable mortalities. We will attempt to synthesise evidence descriptively on burden and impact of rabies in human population as well as the awareness level and effective control and preventive measures from the available studies on rabies from 2010 to 2021 in Bangladesh.

METHODS

The scoping review is planned following the Joanna Briggs Institute methodology and the major guiding steps are: defining the research questions, determining the eligibility criteria with population, concept and context strategy, stating the plan for evidence searching, selection and data collection, searching for evidence and selection of literature by the inclusion criteria, data collection, descriptive analysis and presentation of the data and reporting of the findings. Search will be conducted for both published and grey literature in English language. Blinded screening processes will be adapted to prevent bias among reviewers.

ETHICS AND DISSEMINATION

A scoping review synthesises existing knowledge and does not necessitate ethical approval. Results of this scoping review will be submitted to a journal for publication, presented in relevant conferences and disseminated on social media platforms (eg, Twitter) among the global health stakeholders.

Roles of traditional medicine and traditional healers for rabies prevention and potential impacts on post-exposure prophylaxis: A literature review

Introduction

Globally, traditional medicine is widely used to treat a variety of injuries and illnesses, including dog bites, and exposures that are risky for rabies. However, efficacy of most traditional remedies used for rabies prevention or treatment has not been demonstrated in controlled trials or proven in community-based surveys.

Methods

Six databases were searched including the terms rabies, traditional treatment, traditional remedy, traditional therapy, traditional medicine, and medicinal treatment to review traditional remedies used in the prevention and treatment of rabies. In addition, published literature of rabies transmission dynamics was used to estimate statistical likelihood of dog bite victims developing rabies to provide clarity as to why traditional healers have a high apparent success rate when preventing death from rabies in victims bitten by suspected rabid dogs.

Results

Literature review yielded 50 articles, including three controlled experiments, that described use of traditional remedies for rabies prevention and treatment. Traditional remedies for rabies ranged from plant- or animal-based products to spiritual rituals; however, only a few controlled mice trials were conducted, and none of these trials demonstrated efficacy in preventing or treating rabies. Risk of dying from rabies after a bite from a dog with unknown rabies status is low, 1.90% (0.05%-29.60%). Therefore, traditional healers had a 98.10% (70.40%-99.95%) apparent success rate in preventing death from suspected rabid dog bites despite inefficaciousness of herbal remedies.

Conclusion

There was no universal plant species or route of administration that was consistently used for rabies prevention or treatment across countries. No traditional remedy was efficacious in the prevention or treatment of rabies in randomized controlled experiments. Understanding the cultural context under which traditional remedies are used may facilitate collaboration of traditional healers with the modern medical system to ensure timely and appropriate use of proven therapies for prevention and clinical management of rabies.

Traditional medicine is commonly used worldwide for a variety of ailments and diseases, including animal bite wound care and pre-clinical rabies prevention. Traditional healers often use herbal-based remedies containing local plants. Other traditional remedies include animal-based or spiritual-based methods. This literature review included plant surveys, controlled mice experiments, and community-based studies concerning rabies prevention provided by traditional healers in multiple countries. There was no consistent remedy used across the published literature, and most importantly, there were no published studies supporting effective traditional medicine methods for use in the prevention or treatment of human rabies. Our review of rabies virus transmission rates show that traditional healers have a high apparent success rate of preventing rabies deaths from dog bites, but there is no scientific or medical basis for this perception. Educating communities about proven, effective rabies prevention through post-exposure prophylaxis while understanding the cultural importance of traditional medicine is needed for promoting effective rabies prevention.

Knowledge, attitudes and perceptions about rabies among the people in the community, healthcare professionals and veterinary practitioners in Bangladesh

It is crucial to explore knowledge, attitudes and perceptions (KAP) about rabies among the people in the community, the personnel dealing with animal bite management and suspected rabies patients, including humans and animals, to facilitate intervention in improving rabies elimination strategies. In 2016, we conducted an interactive face-to-face survey in three different districts of Bangladesh to understand the extent of KAP towards rabies in the community peoples (CPs), human healthcare professionals (HCPs) and veterinary practitioners (VPs). A set of prescribed questions was employed to measure what proportion of each group possessed sufficient knowledge, positive attitudes and adequate perceptions about rabies. A total of 1133 CPs, 211 HCPs and 168 VPs were interviewed by using a standard questionnaire comprising both closed and open-ended questions. Of the CPs, 49% identified the disease correctly (i.e. rabies is caused by an animal bite or a scratch). Only 29% of the CPs were aware that a wound should be washed immediately with soap and water after an animal bite or a scratch. However, only 49% of the CPs, 65% of the HCPs and 60% of the VPs felt that it is important to consult a physician and receive post-exposure vaccine as the first line of treatment following an animal exposure. Among the HCPs, 23% of the respondents did not possess sufficient knowledge about animal bites as categorised by the World Health Organization (WHO), and 12% of the respondents did not possess the knowledge on how to manage an animal bite properly. Out of 52% of the VPs who previously treated suspected rabid animals, only 29% had a history of taking rabies pre-exposure prophylaxis (PEP). Lack of formal education and rural subsistence were found to largely contribute to poor rabies KAP level among the CPs (P ≤ 0.01). There has been a high demand for proper training to be provided to HCPs and VPs for the effective management of an animal bite incidence in human and animals, respectively. Multi-sectoral collaboration through integrated One Health initiatives including community education, awareness programmes, facilitation of rabies PEP, and dog vaccination as well as its population control are critical in the way forward to control rabies in Bangladesh.