Animal bites and post-exposure prophylaxis in Central-West Tunisia: a 15-year surveillance data

Factors associated with the spatiotemporal distribution of dog rabies in Tunisia

Despite continuous efforts of veterinary services to control rabies in dogs since 1982, rabies remains a cause of death in Tunisia, with more than five reported human cases in 2022. As little is known on the determinants of transmission of rabies in dogs, better understand which factors contribute to its spatial heterogeneity in Tunisia is critical for developing bespoke mitigation activities. In this context, we developed Bayesian Poisson mixed-effect spatio-temporal model upon all cases of rabid dogs reported in each delegation during the period from 2019 to 2021. The best fitting model highlighted the association between the risk of rabies and the mean average monthly temperature, the density of markets and the density of dogs in delegations. Interestingly, no relationship was found between intensity of vaccination in dogs and the risk of rabies. Our results provided insights into the spatio-temporal dynamics of dog rabies transmission and highlighted specific geographic locations where the risk of infection was high despite correction for associated explanatory variables. Such an improved understanding represent key information to design bespoke, cost-efficient, rabies prevention and control strategies to support veterinary services activities and policymaking.

Rabies in Morocco: Epidemiological Aspects and Post-exposure Prophylaxis Management

Background Rabies is a zoonosis transmitted accidentally to humans and is fatal once clinical signs appear. In Morocco, rabies remains a difficult disease to eradicate, with dogs being the main source of contamination. Transmission of this illness can be avoided by promptly implementing post-exposure prophylaxis (PEP) following animal exposure. Inappropriate or delayed PEP increases the risk of acute infection. This study aims to describe and analyze the characteristics of exposure, investigate the factors related to delay in initiating PEP, and evaluate the attitudes and practices of patients towards animal exposure in the region of Ouarzazate between 2016 and 2019. Methods This was a retrospective study with statistical analysis. The data on animal exposure was collected from the Anti-Rabies Center (ARC) located in Ouarzazate Province, Morocco. Results A predominance of male cases (61.3%) among victims of animal exposure was found. The age group of five to 14 years was the most affected (23.5%). The upper limb represented the most frequent site of exposure (49.4%). Around 52.1% of patients presented with multiple lesions. About 54.4% of cases were bitten by a stray animal. Dogs were responsible for 47.8% of the bites. All exposed individuals performed wound cleansing prior to arrival at the ARC. Post-exposure prophylaxis was initiated in 34.5% of cases between 24 to 48 hours, while 26.1% of cases delayed it beyond 48 hours. Around 34% of patients did not complete their vaccination schedule. Regarding the factors associated with the delay in PEP, we found significant associations with patient age, place of residence (urban or rural), distance from the ARC (>30 km or <30 km), nature, number, and injury status (p≤0.05). Significant associations (p≤0.05) were also found with dog bites and their type (domestic or stray). Conclusion Our findings indicate that better awareness about rabies and PEP management is needed, especially among the rural population.

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.

Time to Revise the WHO Categories for Severe Rabies Virus Exposures–Category IV?

Rabies is a devastating disease and affects millions of people globally, yet it is preventable with appropriate and timely postexposure prophylaxis (PEP). The current WHO exposure categories (Categories I, II, and III) need revision, with a special Category IV for severe exposures. Rare cases of PEP failure have occurred in severe bites to the head and neck. Multiple factors, including route, wound severity, depth, contamination, viral dose, proximity to highly innervated areas and the CNS, and the number of lesions, remain unconsidered. Injuries in areas of high neural density are the most significant considering lyssavirus pathophysiology. Current recommendations do not account for these factors. A Category IV designation would acknowledge the severity and the increased risk of progression. Subsequently, patient management would be optimized with wound care and the appropriate administration of rabies-immune globulin/monoclonal antibodies (RIG/MAbs). All Category IV exposures would be infiltrated with the full dose of intact RIG (i.e., human RIG or MAbs) if the patient was previously unvaccinated. More concentrated RIG/MAb formulations would be preferred. As a world rabies community, we cannot tolerate PEP failures. A fourth WHO categorization will improve the care of these high-risk patients and highlight the global health urgency of this neglected disease.