Rabies in Saudi Arabia: a need for epidemiological data

Camel-related major vascular injuries: A 20-years' experience

BACKGROUND

Majority of human animal-related injuries in the United Arab Emirates are caused by camels. These may involve major vessels and can be life-threatening. We aimed to study the biomechanism, injured regions, management, and outcome of major camel-related human vascular injuries.

METHODS

We retrospectively studied all patients who were admitted to Al-Ain Hospital with camel-related major vascular injury during January 2001 to January 2020. Studied variables included demography, mechanism of injury, injured structures, clinical presentation, vital signs on arrival, associated injuries, surgical management, ICU stay, length of hospital stay, complications, and outcome.

RESULTS

Seven patients were studied; all were males having a median age of 26 years. Five out of six bite injuries (83%) occured during the camel rutting season. The injuries were severe and life-threatening. A camel bite causes four small elliptical wounds of the canine teeth which resembles two stab wounds of 8 cm long, penetrating deeply and injuring major vessels. Four involved the carotid artery, one the femoral artery and vein, one the external iliac vein and one the aorta which was due to a fall from a camel. Although the standard of surgical care was high, the outcome was poor. Six patients were admitted to the ICU for a median of 5 days. One patient died, one became vegetative, and one had arm paralysis.

CONCLUSIONS

Major camel-related vascular injuries have a poor clinical outcome. This is related to the biomechanism of injury which combines penetrating, crushing and blunt trauma. Neck wounds of camel bites can be closed primarily after debridement.

Rabies exposure in travellers to Asia, the Middle East, Africa, South and Central America-a German Airport study

BACKGROUND

Rabies causes thousands of deaths worldwide and trips to rabies endemic countries are popular. Travellers are often uncertain whether pre-exposure prophylaxis (PrEP) is advisable since they find it difficult to estimate the exposure risk during travel and the availability of post-exposure prophylaxis in endemic regions. The aim of this study was to determine the potential rabies exposures in travellers and to assess their knowledge on rabies. Secondly, we explored the access to appropriate post-exposure medical care in respective countries.

METHODS

We conducted a cross-sectional study at Frankfurt Airport. Returning adult travellers arriving from Asia, the Middle East, Africa, South and Central America were invited to participate in this questionnaire-based study while waiting in the baggage claim area.

RESULTS

Over a one-month recruitment phase in March 2019, we enrolled 3066 travellers; 2929 were included in the analysis. The gender ratio was balanced; the median age was 42 years (range 18-83 years). Participants arrived from Asia (46%), Africa (29%), Central/South America (13%), the Middle East (8%) and the Caribbean (8%). Forty-five per cent sought pretravel advice and 22% received ≥2 injections of rabies PrEP. Travellers with pretravel advice from tropical medicine specialists reached significantly higher knowledge scores than others. We found that potential rabies exposure occurred in 2.0% (57/2915) of travellers with 31% (13/42) of the contacts being unprovoked; 19% (8/42) of the exposed sought medical care and 3/8 were adequately treated before returning to Germany. Risk factors for animal exposure were: male sex, young age, trips to Asia and a long stay abroad (>4 weeks).

CONCLUSIONS

A total of 2% of returning travellers (n = 2915) experienced a potential rabies exposure during their journey. A majority of the exposed individuals did not seek medical care; those seeking medical care were often treated inadequately. Rabies information must be emphasised during pretravel counselling and PrEP should be offered generously, especially to travellers with high exposure risks.

Coxiella burnetii in Dromedary Camels (Camelus dromedarius): A Possible Threat for Humans and Livestock in North Africa and the Near and Middle East?

The "One Health" concept recognizes that human health is connected to animal health and to the ecosystems. Coxiella burnetii-induced human Q fever is one of the most widespread neglected zoonosis. The main animal reservoirs responsible for C. burnetii transmission to humans are domesticated ruminants, primarily goats, sheep, and cattle. Although studies are still too sparse to draw definitive conclusions, the most recent C. burnetii serosurvey studies conducted in herds and farms in Africa, North Africa, Arabian Peninsula, and Asia highlighted that seroprevalence was strikingly higher in dromedary camels (Camelus dromedarius) than in other ruminants. The C. burnetii seroprevalence in camel herds can reach more than 60% in Egypt, Saudi Arabia, and Sudan, and 70 to 80% in Algeria and Chad, respectively. The highest seroprevalence was in female camels with a previous history of abortion. Moreover, C. burnetii infection was reported in ticks of the Hyalomma dromedarii and Hyalomma impeltatum species collected on camels. Even if dromedary camels represent <3% of the domesticated ruminants in the countries of the Mediterranean basin Southern coast, these animals play a major socioeconomic role for millions of people who live in the arid zones of Africa, Middle East, and Asia. In Chad and Somalia, camels account for about 7 and 21% of domesticated ruminants, respectively. To meet the growing consumers demand of camel meat and milk (>5 million tons/year of both raw and pasteurized milk according to the Food and Agriculture Organization) sustained by a rapid increase of population (growth rate: 2.26-3.76 per year in North Africa), dromedary camel breeding tends to increase from the Maghreb to the Arabic countries. Because of possible long-term persistence of C. burnetii in camel hump adipocytes, this pathogen could represent a threat for herds and breeding farms and ultimately for public health. Because this review highlights a hyperendemia of C. burnetii in dromedary camels, a proper screening of herds and breeding farms for C. burnetii is urgently needed in countries where camel breeding is on the rise. Moreover, the risk of C. burnetii transmission from camel to human should be further evaluated.

The burden of bites and stings management: Experience of an academic hospital in the Kingdom of Saudi Arabia

Purpose

The main aim of this study is to estimate the economic burden and prevalence of bites and stings injuries in Saudi Arabia.

Methods

A retrospective, cross-sectional study was conducted at King Saud University Medical City (KSUMC) for all bites and stings cases presented to the Emergency Department (ED) between the period June 2015 and May 2019.

Results

A total of 1328 bites and stings cases were treated in the ED at KSUMC. There were 886 insect bites and stings cases, 376 animal bites, 22 human bites, 34 scorpion stings, and ten snakebites. Most cases were reported in April - June. Females account for 62% of the reported cases, and the mean age was 24 years old. The total management cost of bite and sting cases during the study period was 3.4 million Saudi Riyal (SR). The spending cost of the management of animal bites was the highest as it cost 1,681,920.76 SR, followed by insect's management costing 1,228,623.68 SR.

Conclusion

Bites and stings have a considerable health care burden on our society. Although the vast majority of the cases were not associated with a severe life-threatening condition, many were visit ED and associated with high medical costs. Increased awareness of the hazards of animal-related injuries, especially during spring and summer, where most cases take place may lower its incidence and decrease EDs visits.

Animal rabies situation in Sultanate of Oman (2017-2019)

Successful preventive and control measures of zoonotic diseases require updated epidemiological data. Sylvatic rabies is endemic in Oman since 1990. Studying of the prevalence of animal rabies in Oman (2017-2019) was the goal of the current study besides the clinical-histopathological investigations of rabies in different animal species. A total of 117 whole brains of different animal species from different regions of Oman were examined by fluorescent antibody test (FAT) and histopathology for rabies during 2017-2019. Sixty-four samples (54.7%) were positive for rabies by FAT. The most affected species were goat (53.1%) followed by camel (18.8%), which pose a great risk to farmers and veterinarians. Positive fox cases were (10.9%). Most confirmed cases of animal rabies were submitted from Northern regions of Oman. Rabies was reported recently in Al Wusta among wild ruminants, Central Oman. The seasonal cycle of animal rabies in Oman was year-round with the peak from December to April. The clinical signs and neuropathological findings were nearly similar in different animal species. Histopathology-positive cases had Negri bodies in pyramidal and purkinje neurons, non-suppurative encephalitis features, and neuronal degeneration and necrosis. The sensitivity and specificity of histopathological diagnosis of rabies in different animals were 76.47% and 100.00%, respectively. Finally, sylvatic rabies remains a major challenge to the public and animal health in Oman. Although of the value of histopathological diagnosis of rabies if no other technique is available, other complementary tests must be employed to confirm negative results.

First confirmed case of local human rabies in Saudi Arabia

Rabies is a common zoonotic viral infection worldwide. Numerous animals can transmit the virus to humans, but dogs are the main ones. Despite the high incidence of animal bites overall in Saudi Arabia, of which most are dog bites, no single case of confirmed local human rabies has been reported. This article reports the case of a 12-year-old boy who lived with his family in a village in Jazan region in the southeast area of Saudi Arabia. He presented with signs suggestive of rabies. Saliva testing by rabies PCR was positive, confirming this as the first case of local human rabies in Saudi Arabia. The management plan followed the Milwaukee protocol, but the patient unfortunately died after 13 days of admission.

An Overview of the Most Significant Zoonotic Viral Pathogens Transmitted from Animal to Human in Saudi Arabia

Currently, there has been an increasing socioeconomic impact of zoonotic pathogens transmitted from animals to humans worldwide. Recently, in the Arabian Peninsula, including in Saudi Arabia, epidemiological data indicated an actual increase in the number of emerging and/or reemerging cases of several viral zoonotic diseases. Data presented in this review are very relevant because Saudi Arabia is considered the largest country in the Peninsula. We believe that zoonotic pathogens in Saudi Arabia remain an important public health problem; however, more than 10 million Muslim pilgrims from around 184 Islamic countries arrive yearly at Makkah for the Hajj season and/or for the Umrah. Therefore, for health reasons, several countries recommend vaccinations for various zoonotic diseases among preventive protocols that should be complied with before traveling to Saudi Arabia. However, there is a shortage of epidemiological data focusing on the emerging and reemerging of zoonotic pathogens transmitted from animal to humans in different densely populated cities and/or localities in Saudi Arabia. Therefore, further efforts might be needed to control the increasing impacts of zoonotic viral disease. Also, there is a need for a high collaboration to enhance the detection and determination of the prevalence, diagnosis, control, and prevention as well as intervention and reduction in outbreaks of these diseases in Saudi Arabia, particularly those from other countries. Persons in the health field including physicians and veterinarians, pet owners, pet store owners, exporters, border guards, and people involved in businesses related to animal products have adopted various preventive strategies. Some of these measures might pave the way to highly successful prevention and control results on the different transmission routes of these viral zoonotic diseases from or to Saudi Arabia. Moreover, the prevention of these viral pathogens depends on socioeconomic impacts, available data, improved diagnosis, and highly effective therapeutics or prophylaxis.

Rabies among animals in Saudi Arabia

BACKGROUND

Rabies is a fatal viral disease that continues to threaten human and animal health in endemic countries. Rabies is endemic in animals in the Arabian Peninsula. Although Saudi Arabia is the largest country on the Peninsula, little has been reported in the country about rabies situation.

METHODS

A total of 199 animals suspected of rabies from 2010 to 2017, were examined for rabies infection using the Direct Fluorescent Antibody Test (DFAT).

RESULTS

There were 158 (79.4%) positive cases of rabies of the examined animals, Most positive cases were found in Al-Qassim (63), Eastern region (48), Riyadh (25) and Al-Madina (10). Rabies was diagnosed in Procavia capensis and monkeys (Papio hamadryas hamadryas) in Saudi Arabia for the first time. In addition, infected livestock, especially camels, sheep and goat that pose a risk to veterinarians and farmers which increases the risk of potential zoonosis of rabies in Saudi Arabia.

CONCLUSION

These findings indicate that Rabies in Saudi Arabia remain a public health problem and dogs and camels are the main reservoir and continue to present health risks for both human and animals throughout the country, underscoring the importance of applying rabies control measures to animals and humans.

A Perspective on Rabies in the Middle East-Beyond Neglect

Rabies is a neglected but preventable viral zoonosis that poses a substantial threat to public health. In this regard, a global program has been initiated for the elimination of human rabies caused by rabid dogs through the mass vaccination of canine populations. Geographic areas vary greatly towards attainment of this objective. For example, while dog-mediated and wildlife rabies have been largely controlled in major parts of the Americas and Western Europe, the Middle East still grapples with human rabies transmitted by unvaccinated dogs and cats. Rabies prevention and control in the Middle East is quite difficult because the region is transcontinental, encompassing portions of Africa, Asia, and Europe, while consisting of politically, culturally, and economically diverse countries that are often subject to war and unrest. Consequently, one over-riding dilemma is the misinformation or complete lack of rabies surveillance data from this area. This communication is an attempt to provide an overview of rabies in the Middle East, as a cohesive approach for the honing of disease management in each area, based on data compiled from multiple sources. In addition, the related regional transboundary movement of rabies was investigated through phylogenetic studies of available viral gene sequences. Thereafter, the epidemiological status of rabies was assessed for the region. Finally, localities were classified first by the Stepwise Approach towards Rabies Elimination framework and then categorized into four different groups based on management theme: "rabies free"; owned dog and domestic animal vaccination; community dog vaccination; and wildlife vaccination. The classification system proposed herein may serve as a baseline for future efforts. This is especially important due to the severe lack of rabies information available for the Middle East as a whole and a need for a comprehensive program focusing on the entirety of the region in light of renewed international commitment towards canine rabies elimination.

First confirmed case of human rabies in Saudi Arabia

Rabies is an almost invariably fatal Lyssavirus-induced disease, that causes acute encephalitis in humans and other mammals. The viral reservoirs include both wild and domestic animals. The infection causes about 24000 to 60000 deaths worldwide per year (Giesen et al., 2015; Naghavi et al., 2015) with Africa and Asia having the majority of human deaths (95%) caused by rabies. Rabies is endemic in animals in Arabian peninsula. Some countries in the region such as Saudi Arabia, Yemen and Oman are reporting increasing number of cases of wildlife rabies. Among these countries Saudi Arabia is largest, but published data regarding the rabies status in the country are scarce. We report a case of a 60 year old Saudi man who was admitted to cardiac ICU of a tertiary care hospital in Makkah, primarily with history of chest pain for cardiac evaluation, who was found to have signs suggestive hydrophobia. On history, it was found that he had an unprovoked scratch on his face by a dog in Morocco a month prior to admission and his saliva PCR test confirmed rabies virus.

Diagnostic difficulties in human rabies: A case report and review of the literature

Rabies is a zoonotic disease with the highest fatality rate of any infectious disease. The clinical features of rabies encephalopathy are highly nonspecific at the onset and clinicians from low endemic areas usually face difficulties in recognizing cases during the early stages. The need for establishing a rapid and accurate test to identify rabies during the ante-mortem period is important. However, in actual clinical practice, the latter may remain difficult for various reasons. In human rabies, positively identifying the antigen, antibody or genetic material by various diagnostic methods during the symptomatic period is affected by the unpredictable nature of viremia, levels of antibody immune response of the host, and the virulence of the infecting strain. Also, more advanced testing with greater sensitivity may not be readily available at all centers. Here we describe a case of a young male who was bitten by a rabid dog and developed progressive encephalopathy with a fatal outcome, with negative antibodies in the cerebrospinal fluid (CSF). A review of the literature on the clinical features, diagnostic tests, treatment and prevention of rabies is also presented.

Rabies Outbreaks and Vaccination in Domestic Camels and Cattle in Northwest China

In contrast to many countries where rabies has been well controlled in humans and livestock, even in wildlife, rabies is still endemic in almost regions of China. In Northwest China, rabies transmitted by stray dogs and wild foxes has caused heavy economic losses to local herdsmen, as well as causing numbers of human cases. In this study, as part of an investigation of ways to prevent rabies epidemics in livestock, we report an analysis of domestic cattle and camel rabies cases in Ningxia Hui (NHAR) and Inner Mongolia Autonomous Region (IMAR) and the immune efficacy of canine inactivated rabies vaccines in these animals. We found that rabies viruses from these animals are closely related to dog-hosted China I and fox-associated China III lineages, respectively, indicating that the infections originated from two different sources (dogs and wild foxes). As well as the previously reported Arctic and Arctic-related China IV lineage in IMAR, at least three separate phylogenetic groups of rabies virus consistently exist and spread throughout Northwest China. Since there is no licensed oral vaccine for wild foxes and no inactivated vaccine for large livestock, local canine inactivated vaccine products were used for emergency immunization of beef and milk cattle and bactrian (two-humped) camels in local farms. Compared with a single injection with one (low-efficacy) or three doses (high-cost), a single injection of a double dose of canine vaccine provided low-price and convenience for local veterinarians while inducing levels of virus neutralizing antibodies indicative of protection against rabies for at least 1 year in the cattle and camels. However, licensed vaccines for wildlife and large domestic animals are still needed in China.

Rabies virus continues to cross carnivorous species and to infect humans and livestock in China. Rabies vaccination of the principal reservoir animals is even now being neglected in most regions of China, resulting in continuous expansion of rabies epidemics. Since there is no oral vaccine for stray dogs and wild animals and no inactivated vaccine for large domestic animals, rabies is not currently controlled in this country. We report rabies outbreaks caused by bites of dogs and wild foxes and the long-term effects on protection against rabies using canine inactivated vaccines in domestic camels and cattle. Our results indicate that at least three separate phylogenetic groups of rabies virus consistently exist and spread throughout Northwest China. Local canine vaccine products can be used to induce levels of virus neutralizing antibodies indicative of protection against rabies in cattle and camels; however, licensed oral and inactivated vaccines for reservoir carnivores and large domestic animals are urgently needed for elimination of rabies in China.