Prevention of human rabies: a challenge for the European Union and the European Economic Area

Understanding the journey towards rabies vaccination for travellers: Results of a cross-sectional survey with patients and providers in the US, Germany, Sweden, and Switzerland

BACKGROUND

Although cases of rabies in international travellers are uncommon, they are a fatal risk which can be alleviated through vaccination prior to travel. As international travel recovers post-COVID, it is vital that travellers are made aware of the risk of rabies when travelling to endemic countries and supported to receive the vaccine when eligible.

METHODS

Online surveys were conducted in the US, Germany, Sweden and Switzerland between November 2022-January 2023 with both patients and healthcare providers (HCPs). Eligibility criteria for patients included those eligible for rabies pre-exposure prophylaxis (PrEP) due to travel location and activity; HCPs had to be providers of travel vaccinations. In both surveys, questions were asked about discussion of rabies vaccination, decision of whether to administer a rabies vaccine, recommendation to get the rabies vaccine, and final decision to get a vaccine.

RESULTS

The final patient sample included n = 1557 patients who were eligible for rabies pre-exposure prophylaxis (US n = 504, Germany n = 353, Sweden n = 350, Switzerland n = 350) and n = 219 HCPs (US n = 75, Germany n = 75, Sweden n = 32, Switzerland n = 37). Although all patients in the sample were eligible for rabies vaccination, only 15 % felt they were at risk of getting rabies, and only 18 % received the rabies vaccine before their trip. HCPs reported discussing PrEP and/or PrEP and PEP with 30 % of patients presenting for travel vaccination advice, on average.

CONCLUSIONS

Awareness and perception of rabies risk, and lack of consistent HCP discussion of the need for rabies PrEP may be major barriers to uptake of the vaccine for patients who are eligible to receive it.

Zoonoses and pet owners: A survey on risk perception in Northern Italy

Veterinary and human medicine are focused on the issue of emerging and re-emerging diseases, which are especially represented by zoonosis that could be a threat for public health. Zoonotic risk may come from pets: some canine and/or feline viral, bacterial, parasitic, protozoal or mycotic diseases can be transmitted directly to humans. There are several strategies to prevent the transmission of such zoonosis, and among them vaccination plays an important role. Through a survey carried out in Northern Italy aimed to collect information regarding owners' knowledge and perception of the zoonotic risks associated with three zoonoses (rabies, leptospirosis, and dermatophytosis), it was demonstrated that dog owners tend to adhere more consistently to their pets' vaccination schedules and are more receptive to changes in vaccination scheduling compared to cat owners. This study also suggests that cat owners predominantly visit veterinarians for vaccination purposes, whereas dog owners seek veterinary services for a variety of reasons. The survey highlighted the ongoing need to enhance owners' understanding of zoonoses affecting their pets and also the protective role of vaccines. Veterinarians should undertake the responsibility of educating, reassuring, and informing pet owners about the significance of vaccines for their pets and for public health.

Factors affecting the outcome of primary rabies vaccination in young cats

Limited data exist on the factors affecting feline rabies vaccination outcomes during primary immunization. This study aimed to assess if specific factors (signalment, vaccination count, vaccine brand, and time since last vaccination) correlated with meeting global antibody titer standards and absolute titers in young cats given monovalent inactivated rabies vaccines. Analyzing a dataset from cats tested before their first annual booster using the FAVN test, logistic and linear regression models were applied. Among 379 cats, 94.2 % achieved titers meeting or exceeding the standard threshold (≥0.5 IU/ml). Time since last vaccination proved to be the primary predictor of vaccination success. Cats receiving two vaccinations tended toward higher titers. Age, sex, breed, and vaccine type showed no impact on outcomes. The present study indicates that vaccination failure in young cats is uncommon, and that the time interval from the latest vaccination is the single most important predictor of successful rabies vaccination.

Rabies knowledge gaps and risk behaviour in Dutch travellers: An observational cohort study

BACKGROUND

Travellers visiting rabies-endemic countries are at risk of rabies infection. Assessing travellers' knowledge and risk perception of rabies and risk behaviour during travel can help identify knowledge gaps and improve pre-travel risk education.

METHODS

Cohort study in Dutch adult travellers, using two surveys: one before travel to assess knowledge and perception of rabies, and one after return to identify risk behaviour during travel.

RESULTS

The pre-travel and post-travel survey were completed by 301 and 276 participants, respectively. 222 participants had travelled to a high-risk rabies-endemic country. 21.6 % of the participants scored their rabies knowledge as poor. Some participants were unaware cats or bats can transmit rabies (26.6 % and 13.6 %, respectively), or that post-exposure prophylaxis (PEP) is required for certain exposures such as skin abrasions without bleeding or licks on damaged skin (35.5 % and 18.9 %, respectively), while 27.9 % of participants did not know PEP needs to be administered within one day. 115 participants (51.8 %) reported any form of contact with any animal during travel. Two participants reported animal exposure, of which one took adequate PEP measures. Risk factors for animal contact abroad were regularly touching cats or dogs at home or abroad, longer travel duration, having pets during childhood and being an animal lover.

CONCLUSIONS

Pre-travel rabies risk education currently does not meet travellers' needs, which is reflected in knowledge gaps and engagement in risk behaviour during travel. During pre-travel health advice, avoiding animal contact abroad should be emphasized, and additional education is required about indications for PEP.

Real-world evidence of rabies post-exposure prophylaxis in Serbia: Nation-wide observational study (2017-2019)

BACKGROUND

Rabies remains a deadly zoonotic disease, primarily prevalent in Eastern European countries, with a significant global burden in Asia and Africa. Post-exposure prophylaxis (PEP) is critical to prevent clinical rabies. Serbia, a country with a relatively low animal rabies incidence, has been implementing a 4-dose Essen PEP regimen for 13 years. This real-world study aimed to assess the effectiveness of the 4-dose Essen regimen, considering demographic and clinical factors, after WHO Category III exposure.

METHOD

The study included 601 patients who received the 4-dose Essen PEP and 79 who received an additional 5th dose.

RESULTS

Age emerged as a critical factor influencing seroconversion rates after the 4-dose regimen, with older individuals exhibiting lower RVNA titers. Logistic regression indicated a 3.18% decrease in seroconversion odds for each added year of age. The Cox proportional hazards mixed model highlighted age-related risks, with age groups 45-60 and 75-92 at the highest risk of non-seroconversion. Human Rabies Immune Globulin (HRIG) administration was associated with lower RVNA values after the 4-dose regimen, suggesting interference with vaccine immunogenicity among people who received larger doses of HRIG.

CONCLUSIONS

This study provides valuable real-world evidence for rabies PEP in a non-homogeneous population with potential comorbidities. The results underscore the importance of optimizing PEP strategies, particularly in older individuals, and reconsidering HRIG dosing to improve seroconversion rates.

Tracking lethal threat: in-depth review of rabies

An infectious disease known as rabies (family Rhabdoviridae, genus Lyssavirus) causes severe damage to mammals' central nervous systems (CNS). This illness has been around for a very long time. The majority of human cases of rabies take place in underdeveloped regions of Africa and Asia. Following viral transmission, the Rhabdovirus enters the peripheral nervous system and proceeds to the CNS, where it targets the encephalon and produces encephalomyelitis. Postbite prophylaxis requires laboratory confirmation of rabies in both people and animals. All warm-blooded animals can transmit the Lyssavirus infection, while the virus can also develop in the cells of cold-blooded animals. In the 21st century, more than 3 billion people are in danger of contracting the rabies virus in more than 100 different nations, resulting in an annual death toll of 50,000-59,000. There are three important elements in handling rabies disease in post exposure prophylaxis (PEP), namely wound care, administration of anti-rabies serum, and anti-rabies vaccine. Social costs include death, lost productivity as a result of early death, illness as a result of vaccination side effects, and the psychological toll that exposure to these deadly diseases has on people. Humans are most frequently exposed to canine rabies, especially youngsters and the poor, and there are few resources available to treat or prevent exposure, making prevention of human rabies challenging.

Rabies post-exposure prophylaxis of international travellers - Results from two major German travel clinics

BACKGROUND

Travel to regions with rabies risk has increased. However, data on adequate rabies post exposure prophylaxis (PEP) abroad is scarce. The aim of this study was to assess the appropriateness of medical management following suspected rabies exposure (SRE) in international travellers.

METHOD

A cross-sectional questionnaire-based study in returning travellers with reported SRE who sought post-exposure medical care was conducted in two large German travel clinics.

RESULTS

The 75 included SRE cases had a median age of 34 years (range 26-43) and showed a female predominance (59%, 44/75). Most participants returned from Asia (47%, 34/72). About 28% had received pre-exposure prophylaxis (PrEP, ≥2 vaccine doses) (20/71). In 51% the animal was actively approached (34/67). All patients had category II/III exposure according to the World Health Organization (65% category III, 49/75). With 78% (52/67), most patients cleaned the wound after SRE; 36% (24/67) used water and soap. Only 57% (41/72) of participants sought medical care during their trip. Overall, 45% (33/74) received rabies vaccination abroad which corresponds to 80% out of those who sought healthcare (33/41).

CONCLUSIONS

Awareness for appropriate first aid and the urgency of seeking timely professional treatment including PEP after an SRE seems to be insufficient in German travellers. Travel practitioners need to educate travellers about rabies risk, prevention measures and the correct behaviour after SRE including adequate wound treatment and seeking immediate medical help for PEP. PrEP should be offered generously especially to travellers with high rabies-exposure risk and those visiting areas with limited healthcare access.

Performance Comparison of Recombinant Baculovirus and Rabies Virus-like Particles production Using Two Culture Platforms

This work aimed to assess, following upstream optimization in Schott flasks, the scalability from this culture platform to a stirred-tank bioreactor in order to yield rabies-recombinant baculovirus, bearing genes of G (BVG) and M (BVM) proteins, and to obtain rabies virus-like particles (VLP) from them, using Sf9 insect cells as a host. Equivalent assays in Schott flasks and a bioreactor were performed to compare both systems and a multivariate statistical approach was also carried out to maximize VLP production as a function of BVG and BVM's multiplicity of infection (MOI) and harvest time (HT). Viable cell density, cell viability, virus titer, BVG and BVM quantification by dot-blot, and BVG quantification by Enzyme-Linked Immunosorbent Assay (ELISA) were monitored throughout the assays. Furthermore, transmission electron microscopy was used to characterize rabies VLP. The optimal combination for maximum VLP expression was BVG and BVM MOI of 2.3 pfu/cell and 5.1 pfu/cell, respectively, and 108 h of harvest time. The current study confirmed that the utilization of Schott flasks and a benchtop bioreactor under the conditions applied herein are equivalent regarding the cell death kinetics corresponding to the recombinant baculovirus infection process in Sf9 cells. According to the results, the hydrodynamic and chemical differences in both systems seem to greatly affect the virus and VLP integrity after release.

Encephalitis in travellers: A prospective multicentre study

BACKGROUND

As the epidemiology of encephalitis varies from one country to another, international travel may be an important clue for the diagnostic workout of this puzzling disease.

METHODS

We performed an ancillary study using the ENCEIF prospective cohort conducted in 62 clinical sites in France from 2016 to 2019. All cases of encephalitis in adults that fulfilled a case definition derived from the International Encephalitis Consortium were included. Travellers were defined as patients who spent at least one night in a foreign country within the last six months.

RESULTS

Of the 494 encephalitis patients enrolled, 69 (14%) were travellers. As compared to non-travellers, they were younger (median age, 48 years [interquartile range, 36-69] vs. 66 [49-76], P < 0.001), less likely to be immunocompromised: 2/69 (3%) vs 56/425 (13%), P = 0.02, and reported more arthralgia: 7/69 (10%) vs. 11/425 (3%), P = 0.007. The risk of poor outcome at hospital discharge (Glasgow outcome scale ≤ 3), was similar for travellers and for non-travellers after adjustment (aOR 0.80 [0.36-1.80], P = 0.594). Arboviruses were the main causes of encephalitis in travellers: 15/69 (22%) vs. 20/425 (5%) in non-travellers, P < 0.001, and Herpes simplex virus (HSV) was the second (9/69, 13%). Of note, in 19% (13/69) of cases, the risk of encephalitis in travellers may have been decreased with a vaccine.

CONCLUSION

The two primary causes of encephalitis in travellers are arboviruses, and HSV. Empirical treatment of encephalitis in travellers must include aciclovir. Pre-travel advice and vaccination may decrease the risk of encephalitis in travellers.

Nonarboviral Equine Encephalitides

Several viruses transmitted by biological vectors or through direct contact, air, or ingestion cause neurologic disease in equids. Of interest are viruses of the Togaviridae, Flaviviridae, Rhabdoviridae, Herpesviridae, Bornaviridae, and Bunyaviridae families. Variable degree of inflammation is present with these viruses but lack of an inflammatory response does not rule out their presence. The goal of this article is to provide an overview on pathophysiologic and clinical aspects of nonarboviral equine encephalitides, specifically on lyssaviruses (rabies) and bornaviruses (Borna disease).

Preparation and the assessed efficacy of oral baits for the vaccination of free-roaming dogs against rabies

Background and Aim:

Rabies is considered a highly fatal zoonotic disease and many deaths in humans have been associated with dog bites. This study was designed to prepare an oral anti-rabies vaccine in the form of baits to eliminate the disease in free-roaming dogs and subsequently protect humans from dog bites.

Materials and Methods:

The Evelyn Rokintniki Abelseth (ERA) rabies virus strain was propagated in baby hamster kidney cell cultures and adjusted to the recommended dose for application. Four forms of oral baits were employed with the rabies vaccine, which was evaluated for safety, acceptability, and potency in different dog groups. Enzyme-Linked Immunosorbent Assay (ELISA) and the serum neutralization test (SNT) were used to determine the protective rabies antibody titer in the sera of vaccinated dogs.

Results:

According to the results, a dose of 3 mL of the ERA strain, containing a viral titer of 10^7.6 TCID₅₀/mL, induced a mean antibody titer of 25.6 by SNT, and the PI% was 75.7 by Block ELISA, providing a protective level of the rabies antibody in 100% of vaccinated dogs. All used baits were found to be safe, inducing no abnormal general post-vaccination signs (the signs are limited to mild fever, mild loss of appetite, and mild-to-moderate loss of energy for 24-36 h after vaccination).

Conclusion:

It was found that most of the accepted and highly potent bait types consisted of a mixture of wheat flour, vegetable oil, sodium alginate, corn starch, meat meal, cellulose gum, and water. This dog meal was covered with bran and edible wax to seal the bait cavity after inserting the vaccine sachet. This bait was able to induce a protective level of rabies antibodies in 100% of vaccinated dogs after receiving one bait/dog. Hence, such a bait could be recommended for use in the protection of free-roaming dogs and the elimination of the disease.

Flashing Lights, Dark Shadows, and Future Prospects of the Current European Legislation for a Better Traceability and Animal Health Requirements for Movements of Small Animal Germinal Products

Recently, there has been an increasing movement of germinal products of dogs (Canis lupus familiaris) and cats (Felis silvestris catus) between the Member States. Therefore, Europe laid down and harmonized rules on the marking of straws and other packages containing germinal products [Commission Delegated Regulation (EU) 2020/686]. Given that germinal products' movement may increase the risk of infectious disease spread, requirements regarding animal health have been revised focusing on control of rabies and echinococcosis, although there are new emerging diseases that may require, even locally, specific requirements. For this reason, veterinarians, operators, and official veterinarians are involved in different phases of the process. Because non-veterinary operators can operate in all phases, they should have a limited role in collecting germinal products, especially for feline species. Veterinarians, instead, should have a main role in the health evaluation of donors, in collecting germ cells with medical techniques and in depositing sperm and embryos with endoscopic or surgical methods. The official veterinarians are the main ones responsible for the application of the rules. This paper aims to provide an overview of the European legislative framework regarding the newly delegated regulation on germinal products in small animals (dogs and cats), highlighting some of the benefits and critical aspects regarding its functioning.

Spillover of West Caucasian Bat Lyssavirus (WCBV) in a Domestic Cat and Westward Expansion in the Palearctic Region

In June 2020, a cat from Arezzo (Italy) that died from a neurological disease was diagnosed with West Caucasian Bat Lyssavirus (WCBV). The virus retained high identity across the whole-genome with the reference isolate found in 2002 from a Russian bent-winged bat. We applied control measures recommended by national regulations, investigated a possible interface between cats and bats using visual inspections, bioacoustics analyses and camera trapping and performed active and passive surveillance in bats to trace the source of infection. People that were exposed to the cat received full post-exposure prophylaxis while animals underwent six months of quarantine. One year later, they are all healthy. In a tunnel located near the cat’s house, we identified a group of bent-winged bats that showed virus-neutralizing antibodies to WCBV across four sampling occasions, but no virus in salivary swabs. Carcasses from other bat species were all negative. This description of WCBV in a non-flying mammal confirms that this virus can cause clinical rabies in the absence of preventive and therapeutic measures, and highlights the lack of international guidelines against divergent lyssaviruses. We detected bent-winged bats as the most probable source of infection, testifying the encroachment between these bats and pets/human in urban areas and confirming free-ranging cats as potential hazard for public health and conservation.

Current Status of Rabies and Its Eradication in Eastern and Southeastern Europe

The objective of this paper is to provide an overview of the current status of rabies in Europe, with special emphasis on Croatia and Southeast and East Europe. Due to the systematic implementation of a rabies eradication program by oral vaccination of wild animals, by the end of the 20th century, most West and Central European countries were rabies-free. The EU goal was to eradicate rabies in wildlife and domestic animals by 2020. No matter how achievable the goal seemed to be, the disease is still present in the eastern part of the EU, as was notified in 2020 by two member states—Poland and Romania. Croatia has been rabies-free for the last seven years but given that it borders a non-EU country in which a case of rabies was confirmed in 2020, it will continue to contribute to the maintenance of the rabies-free region. A rabies-free EU can only be achieved by continuous oral vaccination, coordination and a regional approach. The prevention of reintroductions from bordering countries in which rabies has not been eradicated yet, and the support for the eradication efforts made by these countries, are goals still pending.

New global targets for NTDs in the WHO roadmap 2021-2030

The second World Neglected Tropical Diseases (NTDs) Day was celebrated on 30 January 2021. To mark the occasion, the World Health Organization (WHO) launched its roadmap for NTDs for the period 2021 to 2030, which is aimed at increasing prevention and control of these too-long neglected diseases. Described here is a global overview on past achievements, current challenges, and future prospects for the WHO NTDs roadmap 2021–2030.

Low risk of transmission of pathogenic bacteria between children and the assistance dog during animal-assisted therapy if strict rules are followed

This study explored the bacterial transmission between patients and dogs during dog-assisted therapy (DAT). Twenty children (55% girls) with a median age of 7 years (range 3-17 years) were included. Two dogs assisted and the conditions were more restricted hygienically with dog 2. Samples from child and dog were collected and cultured before and after each DAT visit. The results showed that dog 1 transmitted bacteria repeatedly to the children. No bacteria were transmitted with dog 2. In conclusion, exchange of bacteria can occur between dog and child during DAT, but it can be reduced by simple infection control measures.

Zoonotic Risk: One More Good Reason Why Cats Should Be Kept Away from Bats

Bats are often unfairly depicted as the direct culprit in the current COVID-19 pandemic, yet the real causes of this and other zoonotic spillover events should be sought in the human impact on the environment, including the spread of domestic animals. Here, we discuss bat predation by cats as a phenomenon bringing about zoonotic risks and illustrate cases of observed, suspected or hypothesized pathogen transmission from bats to cats, certainly or likely following predation episodes. In addition to well-known cases of bat rabies, we review other diseases that affect humans and might eventually reach them through cats that prey on bats. We also examine the potential transmission of SARS-CoV-2, the causal agent of COVID-19, from domestic cats to bats, which, although unlikely, might generate a novel wildlife reservoir in these mammals, and identify research and management directions to achieve more effective risk assessment, mitigation or prevention. Overall, not only does bat killing by cats represent a potentially serious threat to biodiversity conservation, but it also bears zoonotic implications that can no longer be neglected.

Tackling the Threat of Rabies Reintroduction in Europe

Rabies is one of the oldest, most important zoonoses worldwide due to its extreme and inevitably lethal nature, causing one death every 9 min worldwide. Recent reports have demonstrated that the Lyssavirus continues more alive than ever, despite the control carried out against the virus throughout Europe. In this context, this work reviews the main immunological implications, transmission risk factors and current prevention measures for virus control in Europe, and especially in Spain.