Human rabies despite post-exposure prophylaxis: a systematic review of fatal breakthrough infections after zoonotic exposures

Post-exposure prophylaxis (PEP) for rabies is widely administered and highly effective. Nevertheless, sporadic breakthrough infections (ie, rabies in people who have started PEP) have been reported. We conducted a systematic review of articles published between Jan 1, 1980 and June 1, 2022 to characterise breakthrough infections. After reviewing 3380 articles from across all continents, we identified 52 articles, which included a total of 122 breakthrough infections. We classified breakthrough infections on the basis of adherence to core practices (ie, wound cleaning and vaccine administration). Of 86 breakthrough infections with data, median time from exposure to symptom onset was 20 days (IQR 16-24). Most (89 [77%] of 115) participants received PEP within 2 days of an exposure. Severe wounds (defined as those involving multiple wound sites or bites to the head, face, or neck) were common (80 [69%] of 116 [with data]). Deviations from core practices were reported in 68 (56%) of 122 cases. Other possible causes for breakthrough infections included errors in the administration of rabies immunoglobulin, delays in seeking health care, and comorbidities or immunosuppression. Cold-chain integrity assessments and potency testing of PEP biologics were only rarely assessed (8 [7%] of 122 cases), neither of which were found to be a cause of breakthrough infections. Timely and appropriate administration of PEP is crucial to prevent rabies, and although people with high-risk exposures or immunosuppression can develop rabies despite adherence to core practices, this occurrence remains exceedingly rare.

Epidemiological characteristics and post-exposure prophylaxis of human rabies in Chongqing, China, 2007-2016

BACKGROUND

According to the global framework of eliminating human rabies, China is responding to achieve the target of zero human death from dog-mediated rabies by 2030. Chongqing is the largest municipality directly under central government in China. We described the epidemiological characteristics and post-exposure prophylaxis (PEP) of human rabies in this area, in order to provide a reliable epidemiology basis for further control and prevention of human rabies.

METHODS

The most updated epidemiological data for human rabies cases from 2007 to 2016 in Chongqing were collected from the National Disease Reporting Information System. A standardized questionnaire was applied to the human rabies cases or family members of cases as proxy to investigate the PEP situation.

RESULTS

A total of 809 fatal human rabies cases were reported in Chongqing from 2007 to 2016. There was a trend of gradual annual decline about number of cases from 2007 to 2013, followed by stable levels until 2016. Rabies was mostly reported in summer and autumn; a majority of cases were noted in farmers (71.8%), especially in males (65.3%). The cases aged 35-74 and 5-14 years old accounted for 83.8% of all the cases. We collected information of 548 human rabies cases' rabies exposure and PEP situation. Of those, 95.8% of human rabies cases were victims of dog bites or scratch, and 53.3% of these dogs were identified as stray dogs. Only 4.0% of the domestic dogs were reported to have been vaccinated previously. After exposure, 87.8% of the 548 human rabies cases did not seek any medical services. Further investigation showed that none of the 548 cases received timely and properly standardized PEP.

CONCLUSION

Human rabies remains a major public health problem in Chongqing, China. Dogs are the main reservoir and source of human rabies infection. Unsuccessful control of canine rabies and inadequate PEP of cases might be the main factors leading to the serious human rabies epidemic in this area. An integrated "One Health" approach should be encouraged and strengthened in this area; with combined effort it would be possible to achieve the elimination of human rabies in the expected date.

Epidemiological characteristics of human rabies in Henan province in China from 2005 to 2013

Background

Rabies is very common in People’s Republic of China. Henan province, in the central portion of China, is one of the most densely populated provinces in the entire country. With the new rabies epidemic trend noted in northern and western China, it is necessary to investigate the characteristics of human rabies in this area and control the disease.

Methods

We chose patients in hospital isolation in 18 municipalities in Henan province as the investigation subjects. Data were collected through systematic reporting from these hospitals, whereas a questionnaire was applied to the relatives of patients.

Results

A total of 1022 rabies cases were reported. The incidence of human rabies in Henan has increased rapidly since 2005, having peaked in 2007, and maintained a high level in the remaining years. The cases were found mainly in rural areas in the south and east of the province. Rabies was often noted in summer and with the highest number in August. Most cases were noted in males and often in farmers. The patients aged between 40 and 60 years accounted for 36.8 % of all the cases. The wound treatment rate (12.2 %) and vaccination rate (2.6 %) of rabies cases after exposure were relatively low, while the rabies immunoglobulin utilization rate was only 2.8 %.

Conclusions

Rabies epidemic cases at the county level overall were increasing in Henan province during the period of 2005–2013; the epidemic has spread quickly. The data in this study imply that the disease could be better managed by more integrated surveillance across human health and veterinary sectors, improved education and better government policies.

Human rabies in Zhejiang Province, China

OBJECTIVES

To explore the epidemiological characteristics of human rabies in Zhejiang Province, China.

METHODS

Descriptive and statistical analyses were performed using data collected through interview with human rabies cases or their relatives during 2007 to 2014. A standardized questionnaire was used to collect the data.

RESULTS

Two hundred and one cases of human rabies were diagnosed in Zhejiang Province between 2007 and 2014, with a gradually declining annual incidence. Of the rabies cases identified, 61.2% were aged 40-65 years, and the male to female ratio was 2.30:1; 63.7% of cases occurred in the summer and autumn. The two most reported occupations were farmer (69.2%) and rural laborer (15.4%). Wenzhou, Jinhua, and Huzhou were the three cities with the most reported cases. The majority of cases (92.8%) were attributed to canines, and 71.0% of animal vectors were household animals. Less than half of the cases (41.4%) sought wound treatment after exposure. Post-exposure passive immunization was given to 9.7% and active immunization to 2.3%. Cases with a wound on the head/face only had a significantly shorter incubation than those with wounds at other sites (p<0.05); cases with a wound on the hand only had a significantly shorter incubation than those with a wound on the lower limb below the knee only (p<0.001). Non-resident cases were significantly younger (p<0.001) and had a shorter disease duration (p=0.015) than locally resident cases.

CONCLUSIONS

The majority of rabies cases occurred among 40-65-year-old male residents of northern, mid-west, and southeast Zhejiang Province. Further health education is needed to increase the coverage of post-exposure prophylaxis (PEP) in people exposed to possible rabid animals and rabies vaccine use in household animals.

Human rabies: a descriptive observation of 21 children in Kinshasa, the Democratic Republic of Congo

OBJECTIVES

Human rabies has recently emerged as a significant public health threat in Kinshasa, Democratic Republic of Congo (DRC). However, there is little epidemiological information on human rabies especially in children.

METHODS

We performed at Pediatrics Department of General Reference hospital of Kinshasa between December 2008 and July 2009, a retrospective study to assess the incidence and to describe their clinical aspects and outcome.

RESULTS

A total of 21 cases were observed, rather three cases per month. There were 12 boys (57·1%) and 9 girls (42·9%). Biting animal was found to be dog in all cases (100%). The dog was not immunized in all of cases. On admission, all patients (100%) showed furious rabies manifestations. Only two (9·5%) had their wounds treated and received an anti-rabies vaccine (ARV) after the bite incident. Two (9·5%) patients received rabies immunoglobulin (RIG). The case-fatality rate was 100%.

CONCLUSIONS

The disease emerges as a new major public health problem because of a lack of knowledge regarding rabies risk, the poor management of dog bites. Preventative vaccination for rabies should be recommended in the population of Kinshasa, area at high risk to contract rabies, particularly in children.

Control and prevention of canine rabies: the need for building laboratory-based surveillance capacity

Dogs are the source of more than 99% of human rabies virus infections in endemic regions. Without postexposure prophylaxis, almost all cases are fatal, making rabies the most lethal infectious disease. Tens of thousands of deaths are reported annually, but the official figures are believed to be gross underestimates. Controlling canine rabies, especially in free-ranging dogs, is the first priority to reduce the burden of human disease. Because of their limited medical infrastructure, most endemic countries lack the laboratory facilities needed to diagnose human cases of viral encephalitis. Moreover, the veterinary sectors are often unable to undertake systematic surveillance and reporting of rabies in animals. Without an adequate and functioning risk assessment system that is primed for use, rabies will remain a 'neglected' and omnipresent disease, especially in poverty-stricken regions of the world. Fortunately, experience with the elimination of canine rabies from many industrialized countries has shown that these barriers are not insurmountable. Successful rabies prevention and control strategies that prove the absence of the disease depend on laboratory-based surveillance, rapid data reporting and an adequate system of risk assessment. Future control and prevention programmes should therefore coordinate the development of these key factors, creating synergies to eliminate rabies at its animal source. This article forms part of a symposium in Antiviral Research on the global elimination of canine rabies.