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Thursday, May 9, 2013

Rabies re-emergence in Greece

Published Date: 2013-05-06 19:40:52
Subject: PRO/AH/EDR> Rabies - Greece: (North) re-emergence, human exposure 
Archive Number: 20130506.1695562
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases

Date: Thu 2 May 2013
Source: Eurosurveillance, Volume 18, Issue 18, 02 May 2013 [Abridged & edited]

Re-emergence of animal rabies in northern Greece and subsequent human exposure, October 2012 - March 2013.
(By: Tsiodras S, Dougas G, Baka A, Billinis C, Doudounakis S, Balaska A, Georgakopoulou T, Rigakos G, Kontos V, Efstathiou P, Tsakris A, Hadjichristodoulou C, Kremastinou)

Greece has been rabies-free since 1987 with no human cases since 1970. During 2012 to 2013, rabies has re-emerged in wild and domestic animals in northern Greece. By end March 2013, rabies was diagnosed in 17 animals including 14 red foxes, two shepherd dogs and one cat; 104 subsequent human exposures required post-exposure prophylaxis according to the World Health Organization criteria. Human exposures occurred within 50 km radius of a confirmed rabies case in a wild or domestic animal, and most frequently stray dogs were involved.

The last animal rabies case in Greece, dates back to 1987 while the last human case was reported in 1970. Here we describe the re-emergence of rabies in both wild and domestic animals during October 2012 to end March 2013 in northern and central Greece that was associated with human exposure.

Rabid fox:

On 15 Oct 2012, a red fox (_Vulpes vulpes_) exhibited aggressive behavior during daytime, threatening inhabitants of a west Macedonian village in the area of Kozani. The animal was destroyed and transported to the National Reference Laboratory (NRL) for Animal Rabies at the Centre of Athens Veterinary Institutions Virus Department, of the Ministry of Rural Development and Food as part of a wild animal surveillance program for rabies organised and implemented by the Ministry of Rural Development since April 2012 because of documented presence of lyssavirus in neighbouring Balkan countries. Four days later on 19 October, the brain samples tested positive for lyssavirus by fluorescence antibody test (FAT) and molecular techniques i.e. real-time RT-PCR and RT-PCR followed by sequencing.

Rabid shepherd dog and exposure of humans and domestic animals: 

On 10 November 2012, in west Macedonia, near the Greek-Albanian border in the area of Ieropigi, Kastoria, a shepherd dog, belonging to a herdsman, bit the thigh of a passing-by hunter unprovoked. Two days later, on 12 November, the dog developed an aggressive behaviour attacking other dogs and sheep of the herd. It was consequently destroyed and brain tissue samples investigated at the NRL in Athens were positive for lyssavirus both by FAT and molecular techniques on 16 November.

Tracing of exposed humans and animals and first control measures:

An epidemiological investigation was initiated on 16 Nov 2012 by the Emergency Response Center of the Hellenic Centre for Diseases Control and Prevention (KEELPNO), Athens, in order to identify all individuals who had had contact with the dog and possible exposure to the lyssa virus. Seven people possibly exposed were interviewed. Besides the hunter and the shepherd, three relatives of the latter reported close exposure according to the World Health Organization exposure category III i.e. dog bite and/or mucous membrane exposure to the rabid dog. All five including the veterinarian who had sampled the animal received human rabies immunoglobulin along with rabies immunisation series. None of the exposed individuals has developed any symptoms of human rabies so far. 

Results from regular rabies surveillance November to March 2013:

In addition to the two animal cases described, and through the enhanced surveillance instituted by the veterinarian authorities, since November 2012 until end March 2013 we have identified additional 13 red foxes, one shepherd dog (20 December 2012) and one domestic cat (28 February 2013) with laboratory confirmed rabies. In total 104 human exposures (category I: 1; 1%; category II: 21; 20%; category III: 75; 72% and 7; 7% unknown) have been reported to KEELPNO resulting in the administration of post-exposure prophylaxis according to the WHO criteria.

Rabies situation in the Balkans countries:

Although Greece was declared rabies-free in 1987, reports of rabies in wildand domestic animals exist for the neighboring countries. In fact rabies appears to be prevalent in a number of reservoir species in southeastern Europe and in countries north and east of Greece. Recent phylogenetic analyses have shown a westward movement of rabies via the movement of wild animals from Bulgaria to other Balkan countries suggesting that this is a local event unrelated to the circulation of phylogenetically distinct viral strains in Turkey. In addition, in a previous study a distinct group of viruses identified in foxes in Serbia provided evidence for southward movement of rabies from Hungary, Serbia and Romania into Bulgaria . In another report that compared the nucleoprotein sequence among animal rabies isolates from three Balkan countries, including recent isolates from the years 2011-12, all strains belonged to the eastern European group implicating wildlife movement in the transmission of rabies across the region. However, more information is necessary regarding the circulation of the virus and more genotypic data will assist in establishing a pattern for the spread of disease. Only one autochthonous human rabies case was reported in 2009 in the European Union, in Romania, a person bitten by a fox.

The reported cases of confirmed and possible human rabies exposure after domestic or stray animal contact raise important public health concerns: first, there is an urgent need for a prevalence estimate of the virus circulation in wild animals in the area of northern Greece. Such information will help guide immediate vaccination efforts targeting wild animals that are reservoirs for the virus. It is likely that the virus circulates largely in populations of red foxes as red foxes are considered as the most important wild animal reservoir. Second, there is an urgent need for an immunisation program for wild animals. Experience from other countries has shown that rabies elimination cannot solely rely on measures that include farm animals or domestic pets such as compulsory vaccination and/or the control of stray animal population. Reducing population density through culling or sterilisation of the main wildlife reservoirs such as foxes has been the most important factor in rabies elimination in these countries.

Successive oral vaccination campaigns (supported by the European Community) using bait vaccines have been successful in this regard in recent elimination efforts in some European countries for example Estonia but not in others e.g. Latvia and Lithuania. Third, all domestic and stray animals especially in areas where sylvatic rabies is prevalent should be vaccinated; since the majority of the bites originated from stray dogs they should be targeted first. Unofficial information about illegal importation of unimmunised hunting dogs justify the implementation of strict border control, hygiene and immunisation checks and appropriate quarantine during the importation process of such animals according to relevant EU legislation. In Greece, all imported dogs are checked for rabies immunisation with appropriate documentation together with antibody titers and if negative, entry to the country is not permitted. Other strategies pertaining to hunting animals such as the prohibition of hunting with dogs have not been discussed yet; nevertheless, the obligation to keep dogs on a leash is recommended. Fourth, the public needs to be aware about the potential for rabies exposures in areas where the virus circulates in wild animals. Pre-exposure vaccination for high risk groups is a priority in our targeted initial interventions. 

The travel health department of KEELPNO is advising for preventive measures e.g. avoiding contact with wild and domestic animals, special attention for children exposure and pre-exposure prophylaxis only for high risk groups (e.g. game wardens, hunters, veterinarians working in the field) travelling to the affected areas; it also encourages the use of post-exposure prophylaxis according to the WHO guidelines. Currently, the risk of rabies to travellers to Greece remains extremely low and so far only the northern part of the country is affected. Fifth, healthcare workers need to carefully evaluate each human exposure from a potentially rabid animal and take the appropriate actions. Since the human rabies immunoglobulin is expensive, a risk assessment as proposed by WHO should guide a cost-effective approach in its administration.

Last but not least and since the disease was likely introduced to Greece by rabid wild foxes crossing borders in the north of the country, close collaboration with the neighboring countries is of paramount importance especially with regards to control measures in wild animals.

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