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Friday, December 23, 2016

Travel Associated Rabies in Pets and Residual Rabies Risk Western Europe Volume 22 Number 7—July 2016 Emerging Infectious Disease journal CDC

Travel-Associated Rabies in Pets and Residual Rabies Risk, Western Europe - Volume 22, Number 7—July 2016 - Emerging Infectious Disease journal - CDC

Volume 22, Number 7—July 2016

Travel-Associated Rabies in Pets and Residual Rabies Risk, Western Europe

The Study
Conclusions
Suggested Citation

Figure

Table 1
Table 2

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RIS[TXT - 2 KB]

Florence Ribadeau-Dumas

, Florence Cliquet, Philippe Gautret, Emmanuelle Robardet, Claude Le Pen, and Hervé Bourhy

Author affiliations: Université Paris Dauphine, Paris, France (F. Ribadeau-Dumas, C. Le Pen); Institut Pasteur, Paris (F. Ribadeau-Dumas, H. Bourhy); French Agency for Food, Environmental and Occupational Health and Safety, Malzéville, France (F. Cliquet, E. Robardet); Assistance Publique Hôpitaux de Marseille, Marseille, France (P. Gautret); Aix Marseille University, Marseille (P. Gautret)

Abstract

In 2015, countries in western Europe were declared free of rabies in nonflying mammals. Surveillance data for 2001–2013 indicate that risk for residual rabies is not 0 because of pet importation from countries with enzootic rabies. However, the risk is so low (7.52 × 10?10) that it probably can be considered negligible.

Although western and northern Europe and most countries in central Europe have eliminated rabies in nonflying animals (https://zenodo.org/record/49670#) (1,2), alerts are regularly issued because of importation of rabid pets. Policy makers recommend postexposure prophylaxis (PEP) after exposure in Western Europe to bats or pet bites in areas with rabies alerts. However, the policy after exposure to these pets is unclear (https://zenodo.org/record/49670#).

Residual risk for rabies in pets in Western Europe is defined as no risk (no PEP necessary) or low risk (PEP recommended after exposure), depending on recommendations (e.g., no risk according to Public Health England and low risk according to the World Health Organization) (3). Thus, evaluation of residual rabies risk in western Europe caused by pet movement is needed. We evaluated residual rabies risk caused by pet movement in western Europe.

The Study

We calculated the risk that a given pet in western Europe is contagious for rabies on a given day by the equation

We describe factors associated with rabid pets (https://zenodo.org/record/49670#) and define pet transport as any noncommercial movement of a live cat, dog, or ferret and its owner or an authorized person across an administrative border.

During 2001–2013, a total of 21 animal rabies cases attributed to pets from rabies-enzootic countries were reported in western Europe (https://zenodo.org/record/49670#), which represented 1.6 pets/year and 23 days/year of potential contagiousness. Fifteen dogs and 1 kitten originated from rabies-endemic countries outside western Europe. Five dogs raised in western Europe acquired rabies outside this region. One dog subsequently infected 2 indigenous dogs in France (4). All pet owners were identified. All owners except 1 (a Spanish man living in a van) were official residents of western Europe. Circumstances that led to pet examination and rabies diagnosis were clinical suspicion (14 pets), bitten humans (3 pets), border quarantine (2 pets), and retrospective data (2 pets with indigenous secondary cases during the alert in France in 2008).

Average contagious period was 16 days/pet: 14 days in western Europe (8 days without signs of rabies and 6 days with signs of rabies) and 2 days before arriving in western Europe. For 1 dog, signs of rabies appeared before the animal entered western Europe. For each rabid animal, an average of 34 (range 0–187) persons and other animals received PEPs. The maximum value of this range corresponds to an alert in France in 2004. After this alert, 1,200 animals were tested and 759 were observed for 1 year. Human and pet vaccinations led to vaccine shortages that required importing of vaccines not authorized for use in France (5).

We identified animal origin and mode of entry into western Europe (Table 1). Most rabies cases originated in Morocco and were recorded in France. Three cases were imported from eastern Europe to Germany, 1 from The Gambia to France, and 1 from Sri Lanka to the United Kingdom. Customs officials could not identify any of 11 cases in animals transported mainly by road (e.g., after a ferry trip from Morocco to Spain, Portugal, or France). Seven pets were transported through other countries in western Europe before arriving in the country of diagnosis (https://zenodo.org/record/49670#). Six puppies and 1 kitten were transported by air, of which only 2 were identified by customs officials (in the United Kingdom and Germany).

Thumbnail of European Union (EU) regulations (no. 998/2003 and no. 576/2013, http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32013R0576) on movement of cats, dogs, and ferrets, 20032013. Before 2003, national rules applied (e.g., animal checked at destinations, rabies vaccination, animal identification, quarantine, health certification). EC, European community. *http://ec.europa.eu/food/animal/liveanimals/pets/list_third_en.htm. A pet passport is required for pets transported in the E

Figure. European Union (EU) regulations (no. 998/2003 and no. 576/2013, http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32013R0576) on movement of cats, dogs, and ferrets, 2003–2013. Before 2003, national rules applied (e.g., animal checked at destinations, rabies vaccination,...

Of 19 transported rabid pets, 8 (42%) had no rabies vaccination, pet passport, or health certificate. Only 6 were vaccinated (0/2 infected in France, 3/3 imported but raised in western Europe, 3/7 imported by air, and 0/8 imported by road). Most vaccinated pets did not comply with recommended age for vaccination (>12 weeks of age) or time between vaccination, serologic analysis, and transport. No reports mentioned valid rabies serologic analysis included in European Pet Movement Policy (Figure) for unlisted third countries (e.g., Morocco, the Gambia, Sri Lanka, or Azerbaijan) (6). Using data for 2001–2013, we calculated that, for contact on a given day with a pet in western Europe, the probability of the pet being contagious for rabies attributed to pet transport was 7.52 × 10?10 (Table 2).

We observed a significant correlation between number of contagious days for dogs in a country and number of tourists traveling from this country to Morocco (? = 0.73, p = 0.017). We found no correlation with other variables tested (total dog population, dog population density, number of dogs per inhabitant).

Conclusions

Risk for indigenous rabies has decreased in western Europe. During 2001–2013, because of appropriate control of imported rabid pets, only 4 indigenous cases of human rabies were reported (3 in recipients of organs from a donor infected in India and 1 from a rabid bat in Scotland) (https://zenodo.org/record/49670#). Since 2011, no indigenous rabies cases have been reported in terrestrial mammals in western Europe. Because of increased travel (7), rabies imported by trips to rabies-enzootic countries has increased, and travel became the main source of rabies in humans (1.46 patients/year) (8) and pets (1.6 rabid pets/year) in 2001–2013. However, because of improved surveillance, although the number of imported rabies cases increased, the number of secondary cases decreased (https://zenodo.org/record/49670#).

Illegal importation of rabid animals is not limited to western Europe (9) or dogs and cats (10). This finding highlights the need for a global approach for regulation of animal movement worldwide and strengthening real-time reporting for animal and human rabies.

Risk for dog rabies being reintroduced into the European Union from Morocco was estimated as 0.21 cases/year (11). However, we estimate that 1.1 pets/year are entering western Europe after being infected in Morocco. Morocco has become the main source of pet rabies in western Europe, often through Ceuta and Melilla (Spanish enclaves in northern Morocco). Because no prophylaxis or specific vaccinations are needed for travel to northern Africa, few travelers seek pretravel advice and most have little knowledge of pet rabies (12,13).

Lack of awareness also increases importation of human rabies. Despite an efficient policy for preventing entry of rabid pets, the United Kingdom reported the highest number of patients with imported rabies during the study period (https://zenodo.org/record/49670#). Patients returning to this country did not believe that a correct PEP was needed after exposure abroad. None of the transported rabid pets fully satisfied European Pet Movement Policy, which raised questions about how to improve the current regulation application. Increasing international travel, expansion of the Schengen area (26 countries in Europe that have a common visa policy) into rabies-enzootic countries in eastern Europe, and development of internet animal trade (source of illegal importation) (14) are new challenges for ensuring compliance.

Because bat rabies is more difficult to control than dog rabies, and some developing countries still have difficulties controlling rabies, eradication of rabies is not a realistic objective. Awareness should be increased, and current regulations for pet transport should be applied to reduce rabies importation and ensure that risk in western Europe remains low.

To avoid unnecessary and costly PEP and optimize resource allocation, it should be clearly stated which WHO recommendations, Public Health England recommendations, or other practices most relevant after pet exposure should be applied. Low risks (<10-–6) are usually considered acceptable or essentially 0 (3,15). The risk of a fatal car crash while traveling to PEP consultations was higher than the risk of rabies after exposure to a pet in France in 2001–2011 (3). The most pertinent policy in areas at low risk for rabies is probably that of the United Kingdom (i.e., no PEP outside alert areas that do not have asymptomatic animals or exposure to bats) (https://zenodo.org/record/49670#).

Dr. Ribadeau-Dumas is a physician and doctoral candidate in economics at Paris Dauphine University, Paris, France. Her research interests are infectious diseases, public health, health economics, and rabies.

Acknowledgment

We thank Karim Boubaker, Bernard Brochier, Laurent Dacheux, Juan Emilio Echavarria Mayo, Franco Mutinelli, Jacques-André Romand, and Reto Zanoni for providing information on rabies cases; Sylvie Tourdiat for providing assistance with formatting tables and the figure; and Delphine Libby-Claybrough for providing assistance with English editing.

References

Cliquet F, Picard-Meyer E, Robardet E. Rabies in Europe: what are the risks? Expert Rev Anti Infect Ther. 2014;12:905–8. DOIPubMed
Freuling CM, Hampson K, Selhorst T, Schröder R, Meslin FX, Mettenleiter TC, The elimination of fox rabies from Europe: determinants of success and lessons for the future. Philos Trans R Soc Lond B Biol Sci. 2013;368:20120142. DOIPubMed
Ribadeau Dumas F, N’Diaye DS, Paireau J, Gautret P, Bourhy H, Le Pen C, Cost-effectiveness of rabies post-exposure prophylaxis in the context of very low rabies risk: a decision-tree model based on the experience of France. Vaccine. 2015;33:2367–78. DOIPubMed
French multidisciplinary investigation team. Identification of a rabid dog in France illegally introduced from Morocco. Euro Surveill. 2008;13:pii: 8066.PubMed
Servas V, Mailles A, Neau D, Castor C, Manetti A, Fouquet E, An imported case of canine rabies in Aquitaine: investigation and management of the contacts at risk, August 2004–March 2005. Euro Surveill. 2005;10:222–5.PubMed
Regulation (EC) no. 998/2003 of the European parliament and of the council, 2003 [cited 2015 Apr16]. http://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32013R0576
World Tourism Organization. UNWTO annual report 2014. Madrid: UNWTO 2015 [cited 2015 Jun 10].http://www2.unwto.org/annualreport2014
Carrara P, Parola P, Brouqui P, Gautret P. Imported human rabies cases worldwide, 1990–2012. PLoS Negl Trop Dis. 2013;7:e2209. DOIPubMed
Lankau EW, Tack DM, Marano N. Crossing borders: one world, global health. Clin Infect Dis. 2012;54:v–vi. DOIPubMed
Metlin AE, Holopainen R, Tuura S, Ek-Kommonen C, Huovilainen A. Imported case of equine rabies in Finland: clinical course of the disease and the antigenic and genetic characterization of the virus. J Equine Vet Sci. 2006;26:584–7 .DOI
Napp S, Casas M, Moset S, Paramio JL, Casal J. Quantitative risk assessment model of canine rabies introduction: application to the risk to the European Union from Morocco. Epidemiol Infect. 2010;138:1569–80. DOIPubMed
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Gautret P, Ribadeau-Dumas F, Parola P, Brouqui P, Bou
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Rabies in Dogs

Rabies elicits fear in one and all, and very rightly so. It is one of the most dreaded dog illnesses, as there is no cure or treatment for this disease that is caused by a deadly virus. This virus is shed with the saliva of an infected animal. When such an animal bites a healthy animal, the virus enters the body of the bitten creature. It then travels through the nerves to the spinal cord, from where it reaches the brain. A dog that has thus contracted the disease, will not show the symptoms until the virus has reached the brain. The incubation period of rabies in dogs varies greatly. However, it ranges from two to eight weeks.

Symptoms
There are three stages of rabies. A dog may go through any one or all the stages. However, death is certain. As a dog moves through the various stages of rabies, it will show the symptoms specific to each stage. The different stages and their symptoms are:

Prodromal Phase
During this stage, dogs show nervousness and anxiety. While friendly dogs become shy and avoid interaction with human beings and other animals, aggressive canines appear docile. Some may even have fever. Most infected animals constantly lick the part of their body that was bitten. This stage lasts for about 2 to 3 days in dogs.

Furious Phase
Dogs, in this phase, show more erratic behavior. They become restless, more aggressive and show an increased urge to eat, even non-edible things. They are seen roaming or pacing around the house and if caged, dogs are observed to bite and attack the enclosures. Disorientation and seizures are commonly seen. Some dogs suffering from the disease may die or enter the next phase. This phase lasts from 1 to 7 days.

Paralytic Phase
As the nerves in the head and throat are affected, the infected dog will start drooling and will not be able to swallow. Hence, dogs, in this stage of rabies, avoid drinking water or fluids. Due to this behavior, rabies is also known as hydrophobia, which means fear of water. The lower jaw of a rabid dog (dog suffering from rabies) seems to be constantly hanging as the muscles of the face and diaphragm get paralyzed. As the condition progresses, the animal may experience respiratory failure and eventually die.

As soon as one sees any of the rabies symptoms in a dog, the person must inform the local authorities. It is important to stay away from rabid dogs, even if they are pets, as this disease does get transmitted from animals to human beings.

Diagnosis
Diagnosis of rabies in dogs is difficult as they behave normally, until the virus has already infected the brain tissue. A dog may already have rabies virus dividing in the cells of its body, but does not show any physical changes. There are no blood tests either that can confirm the presence of the disease-causing micro-organisms (the virus) inside the body. The only diagnosis possible is to examine the brain tissue of the dog and this is possible only after the animal is dead. So sadly, for dogs suffering from rabies, euthanasia is required.

Treatment
As already mentioned, rabies cannot be treated or cured. Hence, adopting preventive measures against rabies is the best approach to deal with this disease. Vaccination is an important aspect of proper dog care. There are rabies shots for dogs that need to be administered to ensure protection against the virus. Rabies vaccine for dogs involves introducing a small dose of the killed virus into the dogs body. This triggers the production of antibodies in the dog that fight future infection without actually causing the disease.

It is important to minimize exposure of ones pet to wildlife to protect it from rabies. Whenever you take your dog out, leash walk it or keep a careful eye on it. Rabies is very common in wild animals like bats, raccoons, coyotes and foxes. These creatures of the wild are the primary source of infection in domestic animals. Be careful of any rabid animal, even if it appears calm and tame.

Surveillance of rabies is very important to control the disease. Any incidence of a domestic animal contracting the virus should be reported to the authorities. Rabies is not only dangerous to animals, but human beings are also at an equal risk of dying from it. There are a number of cases, where the disease has been transmitted to their human owners. Proper care and timely vaccination are the only way to prevent our canine friends from suffering the miseries of this fatal disease.

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Friday, December 23, 2016